Managed Care

A healthcare delivery system organized to manage cost, utilization, and quality through techniques such as provider networks, referral requirements, and utilization review processes.

Managed care is a healthcare delivery system that aims to control costs while maintaining quality by managing how providers deliver care and how members access services. Most Americans with health insurance are in some form of managed care plan. The main types of managed care plans are HMOs, PPOs, EPOs, and POS plans. Each type has different rules about provider networks, referrals, and out-of-network coverage. What they all have in common is a contracted network of providers who agree to provide services at negotiated rates. For credentialing, managed care means you are enrolling with a specific managed care organization and agreeing to their rules. This includes accepting their fee schedule, following their prior authorization requirements, complying with their quality metrics, and participating in their utilization review processes. Medicaid managed care is a massive segment of the market. Most states contract with managed care organizations to administer their Medicaid programs. Organizations like Molina, Centene (Ambetter, WellCare), Amerigroup, and UnitedHealthcare Community Plan manage Medicaid benefits for millions of members. If you serve Medicaid patients, you are likely credentialing with one or more of these MCOs. Managed care credentialing is generally the same process as commercial credentialing, but some MCOs have additional requirements. They might require specific cultural competency training, quality improvement participation, or compliance with state Medicaid regulations that go beyond standard commercial payer requirements. The managed care landscape shifts regularly. MCOs win and lose state contracts. New plans enter markets. Existing plans merge or get acquired. Staying on top of which managed care plans operate in your area and maintaining active credentialing with each one is an ongoing administrative task.