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TAG reviews managed care services to ensure providers are receiving the proper reimbursement from the entire spectrum of commercial and Medicare HMO payers. There is no standard definition of managed care.  It is a system which provides quality health care while keeping costs down by coordinating or managing services.  A managed care organization may be a group of physicians, a hospital or any organization that is responsible for the delivery of health care to the people enrolled in it.

Commercial Health Insurers:

Most commercial health plan patients are enrolled in managed care plans.  Managed care plans establish specific conditions under which patients may receive benefits; for example, a given medication may be covered only for patients with a certain diagnosis.  Most commercial health insurers offer many versions of the same plan; each version has differing benefit structures, covered services and patient cost-sharing. Plan types include the following:

• Health Maintenance Organizations (HMOs): An HMO provides care through a defined network of physicians, hospitals, and other healthcare providers. Individuals enrolled in an HMO generally cannot receive covered services outside the provider's network. Individuals typically select a primary care physician, who make referrals to specialists when necessary. The HMO usually does not pay for visits to specialists without a referral, or for non-emergency care received from providers that are not designated by the HMOs.
• Preferred Provider Organizations (PPOs): PPOs are similar to HMOs but will generally provide coverage for services provided outside the network. Individuals who go out of network for care typically are responsible for higher cost sharing than they would otherwise be if they received the care in-network. Unlike an HMO, an individual enrolled in a PPO generally may see a specialist without first obtaining a referral from a primary care physician.

Medicare Advantage Plans, (MA) [Medicare Part C]:

Medicare Advantage Plans were designed to give recipients choices other than traditional Medicare coverage that might offer plans that fit a specific lifestyle. Medicare Advantage Plans are health care plans offered by private companies that provide extra benefits and coverage.  With a Medicare Advantage Plan, patients use a health insurance card and may be restricted to see certain doctors or hospitals that are a part of their plan.  Medicare Advantage Plans include:

• Medicare Health Maintenance Organizations (HMOs)
• Preferred Provider Organizations (PPOs)
• Private Fee-For-Service Plans
• Medicare Special Needs Plans

Not all ESRD patients are eligible to join a Medicare Advantage Plan. A patient may be eligible for Medicare Advantage if:

• Patient MA Plans are offered through an employer or a union health plan
• Patient has had a successful kidney transplant
• Patients already in a MA Plan when the patient is diagnosed with ESRD

Many Medicare beneficiaries are choosing to enroll in prepaid managed care plans and primarily health maintenance organizations.  If a patient has permanent organ failure, they cannot enroll in a Medicare HMO.  However, if the patient develops permanent organ failure after joining an HMO, the plan will provide for, pay for, or arrange for the patient care.

To receive Medicare payments, a medical institution must be specifically approved by the federal government to administer organ transplant surgery even if it is already certified by Medicare to provide other health care services.

Managed Care Organizations (HMO) – Payment Methodologies:

Organ transplants financed by managed care organizations are reimbursed by a variety of payment methods, such as:

Global Rate (fixed payment includes physicians) -- Used when a managed care organization and a hospital’s transplant center reach an agreement on a global (dollar) rate.  The global rate usually includes the actual admission for the transplant, admission for complications related to the transplant procedure, professional and technical fees, and a period of follow-up care.  The agreed contract period of follow-up care can last a few days to over a year or more.

Case Rate (fixed payment for a specific episode of care) – Includes the cost of the acute hospitalization for organ transplant.  Usually, technical and professional fees, evaluation, follow-up and procurement costs are reimbursed separately.  Additional hospital stays for transplant services may be eligible for reimbursement if services are related to the original organ transplant services.

Per Diem – Transplant hospitals can be reimbursed on a per diem basis, which usually involves daily average costs or charges.  Under this methodology, a daily rate is calculated and paid to the transplant hospital for transplant care services.

Fee for Service – Discounted charges – (e.g. 80%)

TAG assists hospital transplant centers during contract negotiations, which consist of the following phases:

I)    Phases of Patient Transplant Care                     
        - Transplant evaluation
        - Waiting (pre-transplant maintenance)
        - Transplant admission
        - Post-transplant follow-up

II)    Transplant Contracts
        - Ensure hospital net revenue will cover overall transplant costs
        - Estimated type of patients' coverage contributions
        - Monitor individual managed care contract implementation and impact
        - Monitor non-coverage services and their impact
        - Support hospital transplant personnel in the following areas:
            * Empowered contract negotiator reviews financial impact of all potential sources payment (e.g. Medicare, Medicaid, Hospital, Physician, etc...)
            * Hospital organ acquisition costs
            * Billing patient components and related payments