The union should learn what the protocols are, how they are established, and how actual utilization and denial of care compares with other plans. Many guidelines are geared to patients who do not experience problems or complications beyond those typically expected for their particular condition. Medical reviewers should be permitted some flexibility in their decisions. Access to Care A sufficient number of physicians to service the insured population in each geographic area is key to adequate access. Medical facilities, such as hospitals, outpatient treatment centers and specialty treatment centers, must be conveniently located.
Access also depends on hours of operation and the accommodation of members with special needs.
If hours of operation or waiting times for appointments are unreasonable, then the plan is not adequately accessible. Review the plan's standards for telephone response time, the average waiting time for an appointment and the wait once the member arrives for a scheduled appointment. There are situations where plan members must obtain medical care outside of the plan's network. Most managed care plans require that members obtain a referral to see a specialist. If the plan covers chiropractic or other specialty care, a specified number of visits should be covered without referral.