Managed Care: Introduction

One vital element of every health care provider's practice is reimbursement. Without being paid for their services, the services cannot be offered. In Texas, the 1990s was a decade in which managed care became a primary model of health care delivery and reimbursement, but in 2006, advanced practice nurses (APNs) are still struggling to be recognized as health care providers by some major managed care companies.

In order for advanced practice nurses APNs) to be directly reimbursed for their services in managed care, the APN must be on that managed care company's provider panel. However, except for certified registered nurse anesthetists (CRNAs) who provide approximately 65% of the anesthesia services in the United States, managed care companies were slow to credential advanced practice nurses.

In 1997, CNAP spearheaded a successful effort to include advanced practice nurses in some important managed care patient and provider protection legislation. In addition, HB 2846, also passed in 1997, requires managed care companies to include APNs on their provider panels if the APN's collaborating physician is on the panel and that physician requests the APN also be included. As a result of passage of HB 2846, the Texas Department of Insurance (TDI) adopted rule 28 TAC §3.3701 (adopted by TDI in the July 9, 1999, Texas Register) requiring Preferred Provider Organizations (PPOs) to follow the provisions in Insurance Code 3.70-3C (Use of Advanced Practice Nurses and Physician Assistants by Preferred Provider Plans). Article 3.70-3C has now been codified as §1301.052, Insurance Code. There is also parallel language in the law on health maintenance organizations (HMOs) in §843.312, Ins. Code.

CNAP encourages you to take the necessary steps to become a visible provider in the health care system by applying to be listed on managed care provider panels. Read the CNAP article, Steps for the APN Who Wishes to be on a Managed Care Povider Panel.

The following links provide specific information:     

Steps for the APN Who Wishes to Become Listed on an MCO Provider Panel

Model Letter 1: First Request

Model Letter 2: Second Request

Who to Contact When Denied Recognition By Managed Care Companies

Overview of Managed Care
Describes characteristics of managed care, payment format and provider contracts, and a brief history of managed care.