In a managed care system the PCP (primary care provider) plays an important role. The PCPs responsibility is to provide ongoing and continuous care for the usual patient encounter and to make decisions regarding the referral to other providers within the network for specialty services as needed that are medically necessary. The PCP is a “gatekeeper” who attempts to keep healthcare costs lower by providing essential care, and avoiding non-essential care.
Online Medical Billing Coding – PCP's and Managed Care
Some people may feel that the managed care system attempts to limit costs too much by giving physicians financial incentives to keep costs low. This can be a concern; however, it is a fact that in a non-managed care system many times healthcare costs spiral out of control with unnecessary tests, unnecessary referrals to specialists, etc. When healthcare costs rise to unmanageable levels we all (consumers) pay through higher health insurance premiums and costs. It is smart to use a “gatekeeper” or PCP in a managed care system in order to have someone attempting to give quality care but looking out for the costs involved.
Most primary care providers will get incentives for keeping costs lower. However there are checks and balances within the system. For example, Medicare prohibits the use of “gag clauses” that prevent providers from discussing all treatment options with a patient whether or not their plan pays for such treatment modalities.
Most managed care plans such as HMOs focus a good deal of attention on wellness care and preventing disease and preventing manageable diseases from going out of control by covering many wellness services for issues like diabetes, hypertension, etc. To use an example, a person with high blood pressure that does not see the doctor or get medication may end up in a hospital ER with a brain bleed which can cause death. The entire scenario would cost into the thousands of dollars whereas treating that patient with wellness care- follow up office visits and $10 worth of medication per month would prevent such costs AND save the patient's life.
By: Dawn Moreno, PhD, CBCS, CMAA, MTC. Lives in the beautiful Southwest United States and has been an instructor for medical coding/billing for the past 7 years. Interested in quality medical billing training? Find out More Medical Billing offers
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