MANAGED CARE NEWS online
Volume
I Issue 8
Updates from UnitedHealthcare
New Claims Processing System: As of June 1, 2000, claims
processing and other administrative functions for the UnitedHealthcare HMO,
Select HMO, Medicare Complete, and Medicaid products will be performed on the
new COSMOS (Comprehensive On-line Software for Management and Operational
Support) system, their national claims processing database. The migration of all business transactions
to COSMOS will allow for more consistent claims processing and outcomes, and
will also help improve processes for physicians, groups, and members.
On COSMOS, UHC expects that
95% of clean claims will be processed within 10 business days, 98% of non-clean
claims within 30 business days, and all adjustments will be processed within 4
business days. The average clean claim
is to be adjudicated in 5 business days.
One of the system enhancements for COSMOS is rebundling
review. The enhanced rebundling review
is based on a variety of clinical resources including AMA guidelines, medical
journals, HCFA’s Medicare Carrier Manual, and various medial societies and
associations.
Claims prior to June 1, 2000 will be processed on the
current system (VAX) until all claims are paid.
Please remember that as of
January 1, 2000, all claims should be filed directly with UnitedHeatlhcare. The
claims address for United HMO, Select HMO, Medicare Complete, and Medicaid is
UnitedHealthcare, PO BOX 169087, Duluth, MN, 55816-8261. United Open Access claims should be sent to
UnitedHealthcare, PO BOX 169056, Route 2942, Duluth, MN 55816-8261.
Payer ID Number -Electronic Claims: The Electronic Claims Payor
ID number 87726 must be used for all electronic claims submissions to United
Health Care on or after June 1, 2000.
Change in Pharmacy Benefit Manager: Merck-Medco will manage
pharmacy benefits for all UnitedHealthcare members effective June 1, 2000. Although members will receive a new ID card,
the pharmacy network will essentially stay the same. An updated 2000 Preferred Drug List will be available from
Merck-Medco sometime in June.
If you need additional
information on UnitedHealthcare, please contact japeter@uic.edu.
Humana Reminder - Summer Vacation and Back-To-School
Exams
Immunizations and physical exams are
sometime required for children going to camp, back to school, or for members
going abroad. The following list of physical examinations describes those that
are covered benefits under the Humana plans and those that are not. Please make sure that your services are
coded correctly for appropriate reimbursement.
Covered Exams:
q Physical examinations and immunizations required by law into school.
q Regular preventive medicine physical.
Non-Covered Exams:
q Other physical exams for school, day care centers, camps, or employment.
q Physical examinations required for participation in any type of sports
activity other extra curricular activities.
q Immunizations or physical exams required for entrance into a foreign
country.
Please remember that different health plans
may have different benefit coverage for these types of services. If anyone has
questions they should check with the health plan directly.
BlueCross BlueShield of Illinois
Pap
Tests: Patients can order a free brochure, “ The Importance
of Pap Test Screening for Cervical Cancer,” by calling BCBS of Illinois at
312.653.3465. A copy can also be downloaded from their web site at www.bcbsil.com.
Look for women’s topics under “A Healthy Future” option on the web page.
Smoking Cessation: Member surveys show that many
tobacco users have not been advised in the past 12 months by their physician to
quit using tobacco. It has been shown
that physician advice increases the likelihood of a successful attempt to quit
and physicians are urged to incorporate the following steps into the care of
adolescents and adults:
q At each visit, ask and record the smoking status; make it one of the
vital signs and record it in the medical record.
q Offer smoking cessation advice at every visit; make the message strong
and clear.
q Document this repeated advice; record agreed upon quit plan in the
medical record.
Additional information on smoking cessation
is available at the DHHS Agency for Health Care Research and Quality web site, www.ahcpr.gov <http://www.ahcpr.gov>. BCBS of Illinois has a Smoking
Cessation brochure that can be ordered at no cost through Maureen Rafa at
312.653.8668.
Copay Amounts: While detailed information is not
yet available, new HMO Illinois membership cards will have the office co-pay as
well as the emergency room co-pay on them.
CMS
(Central Management Services) Contract Update
As of July 1st the CMS hospital contract
rates (J code-J75) will increase 2.7 percent.
This contract is specifically for State of Illinois employees covered
under the following self-insured products:
·
Quality Care Health Plan
·
State of Illinois Local Government Health Plan
·
Teachers’ Choice Health Plan
·
College Choice Health Plan (Unicare is the third party
administrator)
Questions may be directed to
Janet Namini at namini@uic.edu.
Managed Care Announces Web Page
The Office of Managed Care will present its new web page
sometime in July. It will make managed
care information more easily available to those who need it. The site will be accessed through a link on
UIC Medical Center web page and is planned to include information on contacts,
reimbursements, eligibility for capitated enrollees, the newsletter and other
information and announcements currently being distributed by other means. We’ll be sharing the “roll out” plans and
more detail about the content over the coming weeks. Stay tuned for updates!
Managed Care - The Current Paradigm
In response to requests for basic information about
managed care, we are presenting a variety of different topics in our newsletter
until this material is made available on our web site. In the limited space available in our
newsletter format only a brief overview of any given issue is possible. We hope that those of you who have not had a
formal introduction to the concepts of managed care will find it useful. Contact the editor for references.
A key factor that shapes the delivery of health care in
the United States is the evolving system for financing or paying for the
services provided to patients. This system is a complex blend of public
(through state and local government) and private (through individuals and
insurers) responsibilities that has evolved steadily since the late 1940’s.
Payment approaches for health care have also undergone
major changes over the past twenty years. The traditional direct “contractual”
relationship between a patient and a physician has for many individuals been
replaced by an arrangement in which a purchaser (usually an employer or a
government agency) and a provider (a physician, a group of physicians, and
hospitals) agree on the types of services and the payment for those services on
behalf of the patient. This describes the
concept of managed care in its most basic form.
Managed care organizations, such as HMOs and PPOs, are
the health care systems under which these purchasing arrangements are carried
out - they provide access to a broad scope of medical services that are
provided for a fixed amount of money, negotiated in advance.
Many kinds of organizations fit under the umbrella of
“managed health care.” Some of the better-known models are presented
below. New models and variations continue
to emerge and the differences between them are often difficult to see. The evolution of these models has generated
a wide range of expectations for managed care in delivering and financing
health services. Insurers, providers,
and plan members except that it will:
q Rationalize
the use of resources
q Shift
the focus from acute care and crisis intervention to disease prevention and
health maintenance
q Contain
and/or reduce health expenditures
q Provide
greater accountability at all levels
q Reduce
physician practice variations, and
q Ensure
better outcomes of care
Debate has intensified on both sides about how
successful this mechanism has been in accomplishing the objectives and there is
now a significant body of literature addressing the shortcomings and negative
consequences of this system.
HMOs. The form of health insurance that has
reshaped the way many people relate to health care is the HMO. While there are many variations on the
model, the essential idea is that a predetermined, annual payment is made by or
for the “enrollee” and then a group of providers delivers all the covered
services for the “capitated” payment.
This is fundamentally different from paying physicians and other
providers on a “piece work” or fee-for-service basis.
There are four distinct types of HMOs differing on
provider payment mechanisms, provider incentives, enrollee incentives,
cost-saving mechanisms, and (financial) risk assumptions: the group model HMO,
staff model HMO, network HMO, and “independent practice association” IPA model.
In general, however, the HMO can be described as an
organized system that provides a specific set of comprehensive health services
to voluntarily enrolled members. Access
to specialists and other services is typically controlled through a PCP who
serves as a gatekeeper in a pre-screening role. Each member pays a periodic, per capita amount that does not
change in relation to the number of extent of services rendered. The selection of treatment and referral to
specialists are generally governed by uniform protocols that restrict a
physician’s discretion. Members pay
nothing or a small amount per visit when they need medical care.
PPOs. Until the mid-1980s, HMOs populated most of
the managed care landscape.
Imperfections in the delivery system led to the introduction of another
model, the preferred provider organization (PPO), and to a variant, the
exclusive provider organization (EPO).
The PPO acts as a “broker” between the insurer and the
provider. There is a contractual
arrangement between a panel of providers and purchasers for a specific set of
services to enrollees. Here the general
concept involves members using physicians who have agreed to give price
discounts to the purchaser. The member
is provided some incentive to use the contracted or “preferred providers” in
the form of lower premiums or out-of-pocket expenses. Providers are usually paid a discounted fee-for-service and in return for
referrals, agree that some aspects of their care will be managed through
utilization review programs and other similar mechanisms.
EPOs are a type of PPO in which the members must
exclusively use the providers within the PPO, although they may pay
out-of-pocket to see out-of-plan providers.
POS
HMOs. The
point-of-service (POS) model is a hybridized HMO plan that offers enrollees a
choice of options at the time they need services. Essentially patients have the option to receive care from
providers not affiliated with the HMO.
One type of POS plan is known as the “triple option” and operates as
follows:
q If the
member accesses medical care within the plan, under the direction of a PCP, HMO
benefits are exercised.
q If the
member sees in-plan providers for in-plan services without the direction of a
PCP, PPO benefits are exercised.
q If
patients seek services from non-participating providers, they are exercising
“indemnity” benefits.
As with other models, lower cost sharing arrangements
helps steer members away from out-of-plan providers and services.
Our series on managed
care will continue in the next edition where information on IDNs, PSOs and a
primer on payment systems such as capitation will be presented.
From the Editor
Over the past few weeks there’s been a lot of activity
on Capital Hill and in state legislatures on health care related issues. The Supreme Court weighed in with an
important decision in favor of HMOs saying that financial incentives given to
providers to hold down costs do not make the HMOs liable to suit in federal
court for violating a duty to put their patients first. Will this have any impact on the patient
rights legislation still languishing in Congress? We’ll recap this and some of the important continuing stories in
the July issue as well as continue our series introducing the concepts of
managed care, which is crafted around questions we receive from faculty and
staff.
Mary Gibson, Editor
The Office of Managed Care, University of Illinois at
Chicago, College of Medicine, presents Managed Care
News online.
Comments or requests should be addressed to the editor at
mgm@uic.edu.