Healthcare Provider Responsibilities in Managed Care: A Comprehensive Guide

The responsibility of the health-care provider within a managed-care organization is to provide high-quality service, control costs and ensure that all care is medically necessary.

High-Quality Service

• Managed-care organizations use third-party administrators (TPA) to monitor the use, quality and delivery of services. The provider must provide 24-hour coverage. Protocols for Medicaid and Medicare plans are established by the Centers for Medicaid and Medicare Services (CMS).

Controlling Costs

• To control costs, providers agree to provide the stated services and assume financial responsibility for the cost of the services. As the primary care provider, she coordinates all other services. The patient must obtain a referral to have all other services reimbursed. Providers are given lists of "in-network providers" to refer patients to. Any other providers are considered out of network and are reimbursed at a lower rate.

Medically Necessary

• Reimbursement is limited to medically necessary services; unnecessary services will not be reimbursed. The providers must use his professional judgment to decide whether treatment is necessary regardless of the approval or denial of a claim. Managed-care contracts clearly state exclusions from coverage.