Survey: Managed Care Programs Accessed by HMOs

To ensure that our services match the needs of our clients, we conducted a survey shortly after forming Summit ReSources. The purpose of the survey was to determine our clients’ survey chartsatisfaction with the managed care vendors they had been accessing prior to the formation of Summit ReSources.  We also wanted feedback as to what types of managed care vendors would be most beneficial. Many of our clients were also contacted by phone or in person to determine what types of managed care programs they currently have in place. All clients have some form of utilization management, consisting of preauthorization for admissions and certain other services, and concurrent review of inpatient admissions.

Disease management programs are primarily internally developed and  focus on the diseases most prevalent within the particular health plan. The sophistication of the programs varies, as well as the degree of outcome reporting. Few health plans have a specific end stage renal disease program, which may be needed in the future.

Almost all clients have contracts with pharmacy benefit managers, which may include reduced pricing for high-cost specialty pharmaceuticals, or they have contracts with separate companies for those drugs. The contracts provide discounts off of the average wholesale prices of the drugs. Some companies also include supplies and home nursing (when medically indicated) as a part of the contracts.

The majority of Summit Re clients  access United Resource Networks (URN) for transplant services and are satisfied with the services provided.

Approximately 25% of our clients have contracted with a neonatal intensive care unit (NICU) management vendor.

About half have some form of out-of-network repricing. Price negotiations are done internally for some health plans or contracted out to a national PPO/repricing vendor.


Did you know?

  • URN access fees for transplant services may be submitted as a reinsurance claim expense if the member reaches the reinsurance deductible.
  • NICU management fees for programs accessed through Summit ReSources are eligible claim expenses if the member reaches the reinsurance deductible.