Managed Care Plans vs. the Fee-for-Service (FFS) System

What Are the Differences In...

...How You Choose a Physician?
  • With FFS, With FFS, you can go to see any physician you want, whenever you feel it is necessary.
  • Under managed care there is a strong financial incentive to see only those physicians who are affiliated with the plan.
...How You Consult a Specialist?
  • With FFS, you can see any specialist whenever you like--though some specialists prefer a referral from your general practitioner.
  • Under managed care you are referred to a specialist only if your primary-care physician determines one is necessary. If you are dissatisfied about not being referred to a specialist, some plans allow you to go out-of-network but you will have to pay a higher percentage of the specialist's bill.
...The Scope of Periodic Checkups?
  • With FFS, FFS periodic check-ups do not include cancer screening tests like mammograms. Nationwide, only one-third of traditional plans cover the cost of a check-up.
  • Under managed care the periodic check-up by a primary-care physician is paid for by the plan and may be accompanied by reminders to get regular preventive screening tests, which are also covered.
...The Average Doctor's Appointment?
  • With FFS, you might not have to wait long to get a non-emergency appointment, but you'll probably spend some time in the waiting room.
  • Under managed care, according to a Consumer Reports survey, members of HMOs have to wait a little longer to get a non-emergency appointment, but their wait is shorter once they're at the doctor's office.
...Method of Payment?
  • With FFS, after paying the yearly deductible (usually the first $200-$500), you will probably be asked to pay the physician's bill up front. Later, you would submit a claim to be reimbursed for a certain percentage of the amount (usually 80 percent).
  • Under managed care you will be charged a $5, $10 or $15 co-payment when you see a doctor. But it is the doctor's responsibility to file the necessary paperwork with the managed-care plan.
...The Quality and Qualification of Physicians?
  • With FFS, qualifications will vary from doctor to doctor. You alone are responsible for checking a physician's qualifications and credentials as well as for making sure you are getting appropriate treatment once you are under a physician's care.
  • Under managed care the plan takes on some of the responsibility of determining whether doctors are qualified when it invites them to join the network. Nationally, about 81 percent of the physicians participating in managed-care plans are board certified.
...Monitoring Members' Satisfaction?
  • With FFS, you are responsible for shopping around to find a physician who you feel gives you good care. The insurance plan's responsibility is limited to payment of claims.
  • Under managed care the plans will actively solicit your opinions on the quality-of-care you have received by means of periodic customer-satisfaction surveys.

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