Managed Care

Your doctor and his Managed Care Coordinators are like the medium that tries to contact the afterlife. They don't always respond to us, and when they do, sometimes the message is fuzzy or garbled. Sometimes it's just plain scary.

Your managed care insurance company is like the rich kid on the playground. They own the football. They make the rules. Both you and your doctor have to follow their rules if we want to keep playing together. Otherwise, they take their football and go home and leave us standing on the playground.rt of your family, become a part of the Geneva Family Practice.

Some of the rules that are most problematic:

• Emergency Room visits for something they deem unreasonable will result in a bill they won't pay.
• X-rays, ultrasounds, Cat scans and MRI's must be obtained at a participating location, and only with a referral. Otherwise, you will be hit with a bill that you can't believe.
• There is NO SUCH THING as a retroactive referral. All services must be authorized before you get them, or you will pay the bill.
• You should try not to go to any ER except Delnor-Community, Provena Mercy, or Rush-Copley unless you are transported to one by an ambulance. Your doctor can't authorize any other ER, even if you call. This is especially true if you are out of town, where you have to use your best judgment, and deal with the insurance company directly after the bills come to you.
• You can't go to a specialist (except a gynecologist or orthopedist in some cases) without a referral from your insurance company, not from your doctor. Your doctor only can suggest a referral, not give you one.
• If a specialist tells you to come back to him, or tells you to get any test (x-ray, lab, etc.) you will be stuck with the bill unless your insurance company gives prior permission.

Referrals (The Benefit Inquiry Process)

Fox Valley Medicine (FVM) is an independent physician association (IPA). FVM subcontracts between insurance companies on the one hand and your physicians and additional providers on the other. FVM handles benefit inquires, authorizations, utilization review, eligibility, and provider contracting . A referral is only generated by FVM, not by your doctor. The physician can only initiate a benefit inquiry, which is the first step towards obtaining a referral.

Contact with your family doctor's office is required prior to a referral request. When the doctor suggests that a referral to a specialist is necessary, a benefit inquiry will be submitted for approval. Our managed care coordinators enter a benefit inquiry into FVM's computer system by modem, and when it is approved, the referral is mailed to your home. Do not schedule an initial appointment to a specialist, a follow-up appointment, or arrange for any services until you have obtained an authorized referral from your insurance company. It will arrive through your family doctor's office. At the specialist's office, please present your referral form at time of service. Payment of services may be denied if you proceed without this authorization, and you could be responsible for the expense.

Fox Valley Medicine provides our office with eligibility information on patients who are assigned to Dr. Rivers, Dr. Fahey and Dr. McNamara. When you are covered by a managed care plan, you are required to choose a primary care physician (PCP). You must be assigned to one of our physicians before we can schedule you an appointment at our office.

ALL services you and your family receive, (except in the case of a life threatening emergency), must be provided by your Primary Care Physician or approved in advance by FVM. There is no retrospective approval. The insurance company does not grant us the power to authorize any out of network expense in any circumstance. You must use your best judgment and seek medical treatment if needed. Then you must appeal directly to your HMO/POS for payment of those services. You will be responsible for the bill if you do not follow these rules.

What do you do if you receive a bill for a referral service?

Although all authorized health care providers are instructed not to send you bills, it is possible that you may receive a bill. DO NOT DISCARD THE BILL! If you received a bill for an authorized service, mail it to: Fox Valley Medicine, PO Box 1868, Batavia, IL 60510. Should you receive a second bill for the same service, please call the Claims Department at 888-227-3362 to verify receipt of the previous billing. All claims require review by Fox Valley Medicine, Ltd. prior to payment to verify authorization of the service.

"SPEAK THE LINGO"

Dictionary (Managed Care and Insurance Lingo)

Benefit Inquiry – The first step towards obtaining a referral. A Benefit Inquiry addresses the patients’ eligibility; benefit provisions and medical necessity. Once authorization is obtained, a Benefit Inquiry becomes a REFERRAL.

Consultation – A visit with a doctor or other healthcare provider to discuss diagnosis and/or treatment; no procedures will be done at this time unless separately authorized.

Fasting Labs – Cholesterol, lipids, blood sugar are a few tests that should be done with the patient fasting. Fasting means nothing should be eaten about 8-12 hours prior to the blood draw. Plain tea, coffee or water is appropriate.

FVM – Fox Valley Medicine. FVM is the managed care subcontracting group that your doctor at Geneva Family Practice is contracted with. FVM reviews all benefit inquiries and negotiates contacts with the insurance companies.

H&P – History and Physical. An H&P is sometimes required prior to surgery to ensure that the patient is in good enough health to undergo the procedure. The PCP or the surgeon can do this. It is usually done one week prior to surgery.

HMO- Health Maintenance Organization. Insurance in which an approval (referral) must be provided for any consultation or services done outside of your PCP's office.

IPA- Independent Physicians Association. Fox Valley Medicine is an IPA which works between the insurance companies and healthcare providers.

Labs – any test (blood, urine etc) done in our office or at an off site lab. This could include any type of blood work, urine cultures or throat cultures.

MCC – Managed Care Coordinator. These are the wonderful ladies that help make all of this happen. Sharon and Pam are GFP’s full time MCC’s. They enter all of the benefit inquiries and prepare all the proper information for your referral.

PCP- Primary Care Physician. Anyone covered by an HMO or managed care plan must be assigned to a PCP. While we at GFP are proud to be Board Certified Family Physicians, PCP will do in insurance lingo. Please don't ever call us gatekeepers, as it is too derogatory for someone with whom you wish to have a good relationship.

POS – Point of Service. A referral is required for many services done by your PCP as well as for tests, labs, and procedures or for a consultation by a specialist.

PPO- Preferred Provider Organization. Under a PPO plan a PCP does not need to be selected yet the benefits booklet will list physicians that are preferred providers. An order by your doctor may be required at times but a referral is not needed.

Referral/"Referral"/order – Sometimes you may be given a verbal referral (recommendation) to see another doctor. If you are covered on a PPO plan this would be acceptable. If you are covered on an HMO a "Referral" will be necessary. This means a benefit inquiry must be presented to Fox Valley Medicine and, when authorized, a referral will be mailed to the patients home. For certain tests a written order from the doctor is all that is necessary.

"TENT DOS" – Tentative date of service. When a benefit inquiry is brought before your insurance company or Fox Valley Medicine for a procedure to be done it must have a TENT DOS. The Date of Service on a referral for surgery is a tentative date only. This doesn’t necessarily mean this service will be done on the date the referral shows.

Quotes from GFP’s MCC:

Paula "With a little knowledge, patients can design their care quite effectively."

Sharon "The referral process should be painless. Don’t be afraid of your HMO."