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Medicare IPA’s, HMO PCP’s and Contracted Hospitals

Understanding IPA’s, HMO PCP’s,  and Contracted Hospitals

Medicare HMO's, IPA's and Contracted Hospitals

We have been receiving a lot of questions about Independent Practice Associations-IPA’s, HMO physicians and how they work together with contracted hospitals and facilities. This blog post will answer several inquiries from our readers.

Independent Practice Associations – IPA’s

Independent Practice Associations are groups of physicians that contract with different Medicare insurance plans, both HMO and PPO. The doctors provide their services on a per capita or flat rate to the managed care organizations. Individual physicians can cut ties with an IPA at any time resulting in a situation where the patient is unable to continue seeing them and must choose a different PCP.

Some physicians will belong to multiple IPA’s and this is very important to know as the specialists and hospitals one can use will not be the same. Here is an example. Doctor Jones is part of 3 different IPA’s:

If Dr Jones is chosen as the PCP with IPA #1 then the hospitals that are available will only be those that IPA #1 is contracted with

If Dr Jones is chosen as the PCP with IPA #2 then the hospitals that are available will only be those that IPA #2 is contracted with

If Dr Jones is chosen as the PCP with IPA #3 then the hospitals that are available will only be those that IPA #3 is contracted with

It is important to really understand which IPA you are choosing when you pick a PCP.

 

HMO PCP’s

A PCP is chosen when someone joins an HMO. This doctor acts as the primary contact for continuing care and when there is a condition that needs to be diagnosed. This doctor will refer a patient to specialist when the need for care is outside the scope of what the PCP can offer. On most HMO plans a patient is able to change their PCP each month.

 

Contracted Hospitals

A contracted hospital is a facility that is contracted with an IPA as a facility that can be used by physicians in that IPA. This is where confusion can start to creep in.

Lets say that Dr Jones belongs to IPA #1. IPA #1 is contracted with 6 different hospitals. Just because Dr Jones is contracted with IPA #1 does not mean he has hospital privileges at IPA #1 hospitals. If Dr Jones wants hospital privileges at one or all of IPA #1’s hospitals he must do so on his own. “Well that’s terrible!” someone might start to think in a panic. No it isn’t.

When you need to see your PCP you do so at his office. If you have a an emergency and are admitted to the hospital your PCP does not operate on you. He doesn’t bring you meals or take your blood pressure or anything really. Your PCP is your first point of contact for routine care and undiagnosed conditions, after that he is basically out of the loop. It’s all the specialists that are within his IPA that will take care of you a particular hospital.

The important thing is to make sure that the physicians group that your PCP is associated with is contracted with the hospital that you would prefer to go to if you ever need surgery. keep the questions coming!

By Cassandra Powers

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