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6 Cards in this Set

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Types of Ancillary services:
1. Diagnostic: laboratory; X-rays
2. Therapeutic.
MCO’s data (“Info Mgmt”) must include:
 type of service
 who ordered it
 cost of the service
HOW TO CONTROL COSTS AND UTILIZATION OF ANCILLARY SERVICES
Modify Physicians’ Behavior
Deal with Physicians’ monetary motivations for high utilzation
 trace ownership of equipment
 track unusually high rates of referral to a given provider
 analyze physicians’ utilization patterns
 ban self-referrals
 or, reimburse them at a low profit margin
 Define Indications for Use (standard protocols)
 only worthwhile for expensive ancillary services
 use Chart reviews
 Limit # of services authorized
Difficulties in Reducing Physicians’ ability to use Ancillary services
 could be medically necessary
 in rural areas, no choice of ancillary providers
 hard to find cheapest facility
 Physicians have legitimate nonmonetary concerns:
 to be diagnostically certain
 patient demands
 fear of malpractice claims

Solutions
 give feedback to physicians:
 comparisons to their peers
 feedback should be adjusted for age/sex
Use Careful Contracting with Ancillary Service Providers
 contract with a very limited network of Anc Providers
 Give providers financial incentives to control utilization
 (through Capitation, Performance-based Ffs, Withhold/Bonus)
 use Global Fees reimbursement
 use a capitated Ancillary Network Manager
Difficulties in Capitating Ancillary Services:
 Capitation under POS plans results in double-paying
 Need large volume of data to compute the capitation rate
 MCO must direct the ancillary services to the capitated providers.
 Best if the Ancillary Service is self-contained

Done.