This may be true even if the doctor feels that the more expensive or uncovered treatment is advisable. Ask if the plan has any type of formal or informal gag clause which would prohibit physicians from discussing all possible treatment options, even those that are costly or not covered by the plan. Some states have passed laws prohibiting gag clauses and the federal government prohibits gag clauses in Medicare and Medicaid contracts. Currently, about 60 percent of managed care plans pay physicians on a capitation basis. Some pay a bonus to those who keep costs below a certain level, withhold some funds and pay them out later for keeping costs low, or apply penalties to those who exceed specified costs.
Many plans restrict physicians from disclosing incentives to limit patient care.
Medicare prohibits these practices if linked to a specific individual. A. Studies show that physicians who own labs perform more tests than physicians who don t. In a true HMO, where doctors are paid on a capitated basis, it is unlikely that they will order unnecessary lab work. However, there may be reason for concern if a PPO or POS doctor sends patients to a lab in which he or she has a financial interest, and then is paid on a per-service basis. The plan should provide a complete written explanation of denials at the time the claim is denied.