Other Important Information About Keystone

The Keystone Plan

How to Get Basic Health Care   |   How to See a Specialist   |   How to Deal With a Need For Emergency Medical Care
How to Get Continuing Care After Emergency Medical Care   |   What Medical Services Need Preapproval
Keystone Participating Providers   |   How to Change Your Primary Care Physician or Referred Specialist
Prescription Drug Discount Program   |   Interpreter Services   |   Other Important Information About Keystone

How Keystone Reimburses Providers
Keystone’s reimbursement programs for health care providers are intended to encourage the provision of quality, cost-effective care for their members. Provided below is a general description of Keystone’s reimbursement programs, by type of participating health care provider. These programs vary by state. Please note, these programs may change from time to time and the arrangements with particular providers may be modified as new contracts are negotiated. If after reading this material you have any questions about how your health care provider is compensated, please speak with them directly or contact us.

Professional Providers

Primary Care Physicians
Most Primary Care Physicians (PCPs) are paid in advance for their services, receiving a set dollar amount per member, per month for each member selecting that PCP. This is called a “capitation” payment and it covers most of the care delivered by the PCP. Covered services not included under capitation are paid fee-for-service according to the HMO fee schedule. Many Pennsylvania-based PCPs are also eligible to receive additional payments for meeting certain medical quality, patient service and other performance standards. These payments can include incentives, which are based on the extent to which the PCP uses available generic drugs as compared to similar PCPs. Additional modifications to the Pennsylvania-based PCP incentive payment system are currently under development. Some PCPs also receive additional payments for assisting in the case management and care coordination of Medicare HMO patients with complex medical problems.

Referred Specialists
Most specialists are paid on a fee-for-service basis, meaning that payment is made according to Keystone’s fee schedule for the specific medical services that the referred specialist performs. Some referred specialists are paid a global fee covering all of the related services delivered during an encounter and therefore may be at risk for the cost of these services. Obstetricians are paid global fees that cover most of their professional services for prenatal care and delivery. PCP referrals to Pennsylvania-based cardiologists or gastroenterologists are valid for ninety (90) days and apply to all covered services provided by the gastroenterologist or cardiologist in his/her office.

Designated Providers
For a few specialty services, (for example, certain rehabilitation therapy, podiatry and radiology services) PCPs are required to select a designated provider to which they send all Keystone patients for those services. Designated providers usually receive a set dollar amount per member per month (capitation) for their services based on the PCPs that have selected them. Before selecting a PCP, Keystone members may want to speak to the PCP regarding the designated provider that PCP has chosen.

Institutional Providers

Hospitals
For most inpatient medical and surgical covered services, hospitals are paid per diem rates, which are specific amounts paid for each day a member is in the hospital. These rates usually vary according to the intensity of services provided. Some hospitals are also paid case rates, which are set dollar amounts paid for a complete hospital stay related to a specific procedure or diagnosis, e.g., transplants. For more outpatient and emergency covered services and procedures, most hospitals are paid specific rates based on the type of service performed. For a few covered services, hospitals are paid based on a percentage of billed charges. Most hospitals are paid through a combination of the above payment mechanisms for various covered services.

Skilled Nursing Homes, Rehabilitation Hospitals, and other care facilities
Most skilled nursing facilities and other special care facilities are paid per diem rates, which are specific amounts paid for each day a member is in the facility. These amounts may vary according to the intensity of services provided.

Ambulatory Surgical Centers (ASCs)
Most ASCs are paid specific rates based on the type of service performed. For a few covered services, some ASCs are paid based on a percentage of billed charges.

Physician Group Practices and Physician Associations
Certain physician group practices and independent physician associations (IPAs) employ or contract with individual physicians to provide medical covered services. These groups are paid as outlined above. These groups may pay these affiliated physicians a salary and/or provide incentives based on quality, production, service or other performance standards.

Ancillary Service Providers
Some ancillary service providers, such as home health care providers are paid fee-for-service payments according to Keystone’s fee schedule for the specific medical services performed. Other ancillary service providers, such as those providing laboratory services, are paid a per member per month amount for each Member. Capitated ancillary service vendors are responsible for paying their contracted providers and do so on a fee-for-service basis.

Medical Technology Assessment is Performed by Keystone

Technology assessment is the review and evaluation of available clinical and scientific information from expert sources. These expert sources include and are not limited to articles published by governmental agencies, national peer review journals, national experts, clinical trials, and manufacturer’s literature.
Keystone uses the technology assessment process to find out whether new procedures or devices are considered to be safe and effective before approving them as a covered service.
If a new procedure or device is not considered to be safe and effective, it will be excluded from adultBasic coverage as “experimental or investigative.” More information available.
When new technology becomes available or when a practitioner or member requests, Keystone researches scientific information available from expert sources. Following this analysis, Keystone makes a decision about when a new procedure or device has been proven to be safe and effective and uses this information to decide if an item becomes a covered service.