CHART COMPARING SPECIALISTS UNDER A FEE FOR SERVICE SYSTEM AND MANAGED CARE SYSTEM – Class 4
The following is a chart synthesizing how Specialists are effected by managed care as compared to fee-for-service:
| How Specialists are Effected |
| Fee For Service | Managed Care |
| Referral or Walk-In | Typically, referral by PCP to specialist on Provider Panel Walk In = (1) Out-Of-Plan (Patient = Self-Pay) or (2) Point-Of-Service ($ out of Patient’s pocket) |
| Autonomy | PCP or MCO continually reviews/authorizes Specialists medical treatment |
| Focus on health care | Focus on health |
| Cost plus profit margin | Reduced Fees/Capitation |
| Specialists own billing form | Uniform billing codes: CPT-4 + Mainly office based and procedures oriented ICD-9-CM = Primarily oriented toward in-patient care |
| Typically, Specialists own judgment in best course of treatment | Varying utilization rules per MCO, example: best course of treatment requiring MCO or PCP’s authorization for continued treatment |
MedicalPracticeCME.com 