HMO's and other forms of managed care are becoming more prevalent. Whether you have just joined a managed care plan for the first time or you have been a member for some time, you may have some questions. This will give you an explanation of how managed care works. The key to success in these plans is in realizing the fact that both you and your doctor have responsibilities in "managing" your care.

• What is managed care?
  
• Who manages?
  
• When should I call my primary care doctor?
  
• If my primary care physician decides I need specialty care, what do I do if the specialist I want to see is not a participant in the plan?
  
• Why can't I go to the emergency room whenever I feel it is necessary?
  
• What about weekends, holidays, and evenings?
  
• Why do I need to get prior authorization for hospitalization?
  
• Are annual check-ups allowed?
  
• How is my annual "Well Woman Exam" dealt with in managed care?
  

Managed care is a form of health insurance that tries to control costs while maintaining a high quality of care. The plans accomplish this by several methods.

1. Using the lowest cost setting to deliver the services needed.
2. Obtaining "volume discounts" by handling patients together and negotiating with hospitals and other providers of care.
3. Recognizing the value of the broad perspective offered by a primary care physician.

The primary care doctor (typically a family physician, internist or pediatrician) is the "point person" who manages managed care. You have chosen us as your primary care physician. If you are in need of prevention care or treatment of an illness, you should contact us. It is our responsibility to see to it that you are seen in a timely fashion and treated appropriately. If there is a need for additional medical care, such as a consultation or treatment by specialist, we will assist in arranging for that care, including assistance with the authorization process through your health plan. We will consider the recommendations of the specialist and, if appropriate, authorize them. You will sometimes be given an authorization form for the consulting specialist, typically good for one visit within a limited time period.

It is important that you NOT make appointments and/or see specialists or consultants without authorization through our office since the health plans do not accept retroactive authorizations for such visits. As a result, the bill will not be paid by your plan for any visit to a specialist that did not undergo the referral process in advance.

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You should call whenever you believe you have a problem that requires your being seen or about which you feel uneasy. You should also call for your health maintenance exams on a routine basis.

If you feel you have a true emergency, you should call 911. In most instances however, it is more appropriate to reach the physician on call and decide together if an emergency room visit is appropriate. If you do transport yourself to an emergency room without speaking to a physician first, your health plan will make a decision about payment for that visit. We, as your primary care physicians, cannot do retroactive authorizations for emergency room visits about which we were not contacted before your arrival. However, you should notify us afterward in any case so that we stay informed about your health. Please refer to your specific health plan's policies on the emergency room for more information.

For less urgent problems, our offices are ready to take your messages, at which point we will gather your chart and give all the information that you've given us to the doctor and his or her nurse. In most case we return our phone messages on the same day and we do appreciate guidance from you as to when is best to call you. Lastly, be sure to call and cancel your appointments if you are unable to come.

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Usually, it is possible to find a physician within the plan who has the same abilities, background and other attributes as the requested physician. Rarely, the specialist needed is so unique that no substitute can be found. On such occasions, we may be able to negotiate with the health plan to obtain authorization.

Emergency rooms are very expensive and can't provide follow-up care. More extensive testing is often done than would be necessary if you were seeing your primary care doctor. Our records and our ability to see you again soon (if necessary) are two important components of providing you with continuous and coordinated care in an urgent setting.

Each of our offices has a doctor on call, you may be able to handle the problem with the advice given. You may also be advised to call for an appointment the following day. If there is an urgent need to be seen, the doctor will either see you or authorize a visit to another doctor or an emergency room. If you are out of town and become ill, seek appropriate emergency care and call us during the next business day to let us know of your condition.

Because hospitals and their technology are costly, they must be used as efficiently as possible. That is why it is necessary, in the case of elective admissions, to plan out in advance how long you are expected to be in the hospital and what procedure is planned.

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Managed care plans strongly support preventive care, including periodic check-ups. The frequency of such check-ups depends on your age and your particular health plan. Infants and young children have check-ups more often, whereas older children and adults do not need to be seen as frequently. Some plans do have a check-up schedule over and above which they do not pay for further health maintenance. Also, some plans do require that camp or school physicals that might fall in between these planned check-ups be paid for privately.

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Most managed care plans allow for one Well Women Exam per year. Our physicians routinely provide this service as part of complete care for women. Many of our patients choose to combine this with a thorough general exam. However, most managed care plans allow women the option of having this exam performed by a participating gynecologist. If you choose to see the gynecologist and a problem is detected which our doctors are trained in treating, you will be asked to follow up with us if you want your health plan to cover the service. This includes "follow-up Pap smears." If the problem is one that our physicians feel requires more specialized service (gynecological, surgical, etc.), the appropriate referral will be completed. For gynecological problems that occur in between your annual exams, we ask that you schedule an appointment with us so that we may evaluate you.

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