decisionhealth Newsletters, Answer Books - 2009 Issue 2 (February)
Medicare Managed Care / Private or Federal, Managed Care is Here
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Article Overview
This article explains the impact of managed care on Medicare and other practice settings and highlights the operational issues that matter to coders, clinicians, and office staff. It focuses on broad topics such as contract expectations, referral-based coverage, the coder’s role in communicating with carriers, and the significance of NCQA accreditation and record review standards.
Why This Topic Matters
Managed care changes how practices document, communicate, and manage coverage expectations. Understanding these general issues helps medical offices reduce denials, align services with contracts, and prepare for accreditation-related record review.
Article Sections
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Managed care and Medicare overview
Introduces how managed care affects Medicare and other health plan arrangements. Discusses the broader shift in relationships among insurers, physicians, and patients.
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Contracting and covered services
Describes the importance of having services identified in managed care contracts. Covers general concerns about furnishing services that may not align with the agreement.
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Referrals and authorization workflow
Explains the role of referrals in managed care and why pre-service approval processes matter. Also addresses office workflow considerations when services are not authorized in advance.
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Coder responsibilities and utilization review
Discusses the coder’s role as a communication link between the practice and the carrier. Mentions utilization review in the context of managed care payment and reporting.
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NCQA accreditation and record review
Summarizes the importance of NCQA accreditation for managed care plans and provider offices. References the general areas examined during record review and preparation for standards compliance.
What You Will Learn
- How managed care changes practice relationships and coverage expectations
- Why contract language matters for services performed under managed care plans
- How referrals and authorization influence managed care coverage processes
- What role coders play in managed care communication and utilization review
- Why NCQA accreditation and medical record review are important to managed care operations
Who Should Read This
- Medical coders
- Practice managers
- Physician office staff
- Clinicians participating in managed care
- Billing and reimbursement professionals
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