1. The Blue Plans, Private Insurance and Managed Care Plans Chapter 11

2. Healthcare Reform Cost of healthcare High tech equipment Expensive medications Uninsured Americans Fraud Inefficency

3. Managed Care Systems EPO “Exclusive” Regulated by insurance statutes FMC Member physicians bill foundation directly Reimbursement is proportional to number of medical services delivered

4. Managed Care Systems IPA Contractual arrangement to treat HMO patients Discount of up to 30% PPO Coinsurance requires patient to pay 20-25% of allowed amount “network discount applied” Pre-certify

5. Managed care Systems PPG Flexible Portion of physician income covers joint expenses Physician owned POS Primary care Physician Use network Providers

6. Quality Improvement Organization Medically necessary, appropriate and meet standards of care AKA Professional or Peer Review Organizations Review and recommend action

7. Utilization Review/Management Appropriate and efficient use of resources Cost effective manner

8. Preauthorization/prior approval VERY IMPORTANT! Unknown to patients Must be medically necessary service ALWAYS CALL!