Managed Care

Managed care is an approach to healthcare intended to streamline services and provide healthcare that is quality and cost effective. Through supervision, monitoring, and advising, managed care programs seek to ensure a certain standard of care, measure performance, and control costs. Additionally, some managed care plans seek to assist members in staying healthy through prevention.

Managed care plans typically cover some or all of the costs of obtaining healthcare services. Members of such plans are usually encouraged, if not required, to seek services from within a network of approved providers. Some managed care plans allow members to obtain services from providers outside the network. However, such plans usually cover less of the bill when a participating provider is not used.

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.

Unless it is an emergency, 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 and Dr. Fahey. 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 receives, (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 retroactive 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.

The following suggestions are intended to make your experience with managed care easier and less costly for you individually.

• Your doctor’s office does not give you a referral.  Our role is to submit a request for a referral to your insurance company.  You cannot see a specialist without a referral from your insurance company.
• 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.  If these tests are obtained without the proper referral you will be billed at a much higher rate.
• 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 cannot authorize any other ER, even if you call.
• If you happen to be out of town you must use your best judgment, and deal with the insurance company directly after the bills come to you.
• Referral requests are submitted from our office every day and we do our best to have them approved for you as quickly as possible. 
• If a specialist tells you to come back to him, or tells you to get any test (x-ray, lab, etc.) you MUST obtain new referrals before obtaining these services.

Managed Care Terms

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. A type of insurance coverage 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.  At Geneva Family Practice Pam, Karen and Laura are our 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.  At GFP we are proud to be Board Certified Family Physicians, and are qualified to be your primary care physicians.

POS – Point of Service. A type of insurance whereby 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.  A type of insurance whereby 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 patient’s 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.