Managed Care

Posted by Melda Research on March 29th, 2019

A Managed care plan refers a health-care delivery system, which integrate financing and health care delivery. These plans have many characteristics, several of which relate to those of insurance and have thus gotten referred as managed insurance. In fact, they avail a wide range of health insurance products to a customer (Peter, 2009).

One role of insurance is to meet critical needs of the insured within best time frame and facilities. In accordance to that managed care organizations assign patients with specific clinical needs to specific hospitals or a network of hospital designated as Center of Excellence (Green & Rowell, 2008). These hospitals may get chosen because they meet criteria developed by the plan including quality of care goals and competitively priced services. To ensure insurable services, Centers of Excellence employ board certified physicians to operate in their programs. These centers get required to meet specific credentialing criteria. That includes hospital, support services such as the laboratory and pharmacy, not exempting its personnel.

The enactment of managed care system of health care delivery was through a shift from the indemnity plans. These were the primary health insurance plans prior to their shift to managed care plans. Indemnity plans required the member to prepay premiums in exchange for a particular amount of monetary coverage in the occurrence of an accident or illness. Managed care plans today offer a fee-for-service form of reimbursement based on specific services provided to the plan member. Another rule of the system is that the physician or the supplier of service get paid a specific amount for that specific service rendered in accordance with the fee-for-service plan. That marks another reason managed care is considered managed insurance (Green & Rowell, 2008).

Managed care programs possess many features, which directly or indirectly get viewed as insurance-featured.

Co-Payments: Co-payments refer a portion of the fee for services for which a member is responsible for making. The plan companies assume or believe that, having an insured patient get responsible for a portion of the total bill would affect the patient's decision to see a doctor. Managed care companies place a responsibility insurance to collect the required co-payments for the patients (Green & Rowell, 2008).

Prior Referral before Treatment: Several of managed care plans require that a patient should first obtain an insurance referral from their initial care physician (PCP) before being permitted to access of their care. Specialists who diagnose managed care patients with no prior referrals may not get reimbursed by the insurance plan for their services. Victim patients without insurance referrals risk being 100% responsible for the costs. That means that managed care organization works in full conjunction with insurance (Green & Rowell, 2008).

Prior Authorization: Being insured by managed care creates a responsibility for obtaining authorization from the insurance company before surgery or hospitalization. In various cases, the managed care organization would require the opinion of a second physician before (Green & Rowell, 2008).

These features and several others not mentioned show that managed care delivery systems are innovative in both content and form. Today's consumers get assured of an evolving world of managed care. These plans evolve to ensure patients through the provision of attention to the quality of care and cost savings services. The insured persons are required to pay premiums while those notwithstanding pay on a fee-for-service basis. All the above points that managed care plans are indeed befitting to get pronounced managed insurances. (Green & Rowell, 2008)


Peter R. (2009). Managed Care Plan: What It Is and How It Works. London: Jones and Bartletts Publishers

Green  A., & Rowell, J. (2008). Understanding of health insurance: A guide to billing and reimbursement. Clifton Park, NY: Delmar Cengage Learning

 Sherry Roberts is the author of this paper. A senior editor at MeldaResearch.Com in best nursing essay writers. If you need a similar paper you can place your order from custom nursing papers.

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Melda Research
Joined: January 25th, 2019
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