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Navigating the System
The Primary Care Physician holds the keys to smooth sailing through the Managed Care Organization (MCO). The function of the Primary Care Physician is to:
- Coordinate all aspects of an individual’s medical care
- Authorize referrals to specialists
- Write prescriptions for medications and durable medical equipment (e.g. wheelchair, hospital bed, etc.)
- Order all diagnostic testing (e.g. x-rays, CT scans, etc.)
- Be available by phone 24 hours a day
- Provide treatment when a person is ill or help prevent illness.
In order to successfully navigate a Managed Care Organization (MCO), you need to be an informed health care advocate. On the following page, we have included a list of questions, which we hope will be very helpful. As you look at these questions, reflect o the individual’s relationship with his or her Primary Care Physician. How do you rate the relationship? If necessary, are there steps you can take to be a more informed advocate and, as a result, build a better relationship?
Are You An Active Health Care Advocate?
- Do you take a list of questions or concerns when you go to the doctor with the person?
- Do you encourage the doctor to talk to and with the person rather than you?
- Do you make sure all the individuals symptoms are described, even if the doctor seems in a hurry?
- Do you tell the doctor about medications the individuals has taken which have either not helped or had unpleasant side effects?
- Do you tell the doctor about medications and or treatments that have worked well?
- Do you ask for information about possible reactions and side effects to prescribed medications and/or treatments?
- Do you disagree with the doctor if a treatment doesn’t seem as if it will work?
- Do you ask for referrals to other doctors/specialists when other care is needed?
- Do you feel comfortable asking for referrals to physical, occupational, and/or speech therapists, if needed?
- Do you ask questions if you do not understand what the doctor is telling you?
- Do you keep asking questions until you understand what the doctor is saying?
- Do you get any needed directions in writing from the doctor?
- Do you telephone, write, or visit the doctor with the outcome of your treatment?
Tips for Navigating the Managed Care Organization (MCO)
It is of utmost importance to have certain information available. It is the individual’s right as a health care consumer to request or have you request the following important materials from their Managed Care Organization:
- Member handbook explaining the benefits package
- Provider directory which lists medical providers that should be utilized in the MA HMO network (e.g. PCP, specialist, dentist, pharmacist, durable medical equipment company).
- Member card with identification number
When you call the Managed Care Organization with a problem, remember to keep a record of the names of people you talk with and the content of the telephone conversation. Save and put all telephone records and correspondence received from, and sent to, the Managed Care Organization in a safe place.
The gathering and coordinating of information go hand in hand. Together they will help to more easily and effectively communicate the person’s needs. Clear and complete information may clarify any questions and may even resolve conflicts before they occur.
The following tips may help you communicate more effectively when calling the Managed Care Organization:
- State the person’s name, identification number, and the reason for the call.
- Wait until the Managed Care Organization representative has all of the information before you ask questions or explain the problem.
- Ask only one question at a time and do not go on until you clearly understand the answer.
- Address each issue involved in the problem.
- Ask the Managed Care Organization representative to “walk you through” the steps of what you need to do to get what the person needs. Record this information and read it back to the representative to be sure the information is correct.
- If the Managed Care Organization representative wants to call back, give him or her a deadline date. Get the name, number and department of the representative.
- Call him or her again if you do not hear back. Don’t be shy. Remember, “the squeaky wheel gets the grease”. (The person who persists is heard).
- If the Managed Care Organizations representative needs to transfer you to another department, get the name and number of the new department in case you are disconnected.
- If you are transferred to various departments, such as Case Management or Utilization Review, make sure you get separate names and numbers and keep them in your file. You never know when a contact may come in handy!
- If you are not satisfied with the service, ask for a supervisor.
- Be patient but persistent and assertive!
You are now making headway toward becoming an active, informed health care advocate and you can begin to navigate the Managed Care Organization with ease and confidence.
Solving Problems
If you find the person you support in stormy waters with a problem you cannot resolve, you may be able to calm the waters by speaking with the Primary Care Physician. If your problem still remains unresolved, you can request a second opinion from another physician in the Managed Care Organization network.
Another avenue to assist you in problem solving is the Special Needs Unit of the Managed Care Organization. Telephone numbers for the Special Needs Units are listed below.
Also remember you can always contact PCHC (215-546-0300, ext. 3660) for support with accessing quality health care and in resolving your dilemmas.
Another way to get what is needed is through the Program Exception Process. This is the Managed Care Organizations' process for considering providing for medically necessary treatments, services or equipment not normally covered. When requesting special medical services or durable medical equipment through this process utilize the following:
- Have the Primary Care Physician, Specialist or Dentist write a letter of medical necessity with the following information: a diagnosis, a description of condition, a description of possible extenuating circumstances, and a description of preventive qualities of service or equipment requested.
- The Primary Care Physician and/or Specialist then submits this letter of medical necessity to the Managed Care Organization for approval.
- At the same time, mail or fax the letter of medical necessity and any other pertinent information (e.g. prescriptions, bills, etc.) to the “attention of” the Special Needs Unit of the Managed Care Organization.
No Resolution In Sight
When there is no resolution in sight, there are other alternatives. The person should file a complaint, grievance, or appeal with the Managed Care Organization. The addresses of Grievance and Appeal Committees are below:
Americhoice Health Plan
100 Penn Square East
Suite 900
Philadelphia, PA 19107
Attn: Grievance Coordinator
Health Partners Health Plan
833 Chestnut St.
Suite 900
Philadelphia, PA 19107
Attn: Grievance Coordinator
Keystone Mercy Health Plan
P.O. Box 41820
Philadelphia, PA 19101
Attn: Grievance Coordinator
Board of Appeals
Office of Hearings and Appeals
Department of Public Welfare
6th Floor Bertolino Building
P.O. Box 2675
Harrisburg, PA 17105
Bureau of Health Care Financing
Department of Health
Room 1026 Health and Welfare Building
P.O. Box 90
Harrisburg, PA 17108
Recommended List of Documentation to File A Grievance or Appeal
- Letter of medical necessity from the Primary Care Physician
- Supporting letters of medical necessity from other medical specialists (e.g. Podiatrist, Cardiologist)
- Prescriptions from Primary Care Physician
- Previous correspondence received from the Managed Care Organization.
- Statement of what benefits are covered by Medical Assistance
- Denial letters from the Managed Care Organization, Medicare, and/or private insurance
- Polaroid pictures of injury, wound, etc.
- Telephone Documentation Log recording contacts with the Managed Care organization representatives.
When Change is Necessary
If navigating the waters of the Managed Care Organization gets too choppy and change becomes necessary, you can “bail out” the person you support. The individual has the right to change either his or her Managed Care Organization or Primary Care Physician or both.
To change the Primary Care Physician, call the Member Services of the Managed Care Organization with the name and address of the new Primary Care Physician. To change your Managed Care Organization, call the HealthChoices (Benova) Hotline at 800-440-3989.
Key to Managed Care
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