Gatekeeper Model
The HMO mechanism routing access to specialists through the primary care physician's referral, controlling utilization and cost.
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Practice This Concept
In a managed care plan that uses a gatekeeper, what is the gatekeeper's primary function?
A primary care physician who coordinates the insured's care and authorizes referrals to specialists — A gatekeeper is the designated primary care physician through whom care is coordinated in managed care plans, particularly HMOs. The insured selects the gatekeeper, who manages routine care, maintains the medical record, and issues referrals before the insured can see a specialist or obtain non-emergency services. The gatekeeper model is how managed care controls both cost and utilization: it directs patients to appropriate care and avoids unnecessary specialist visits. Because the gatekeeper role is part of the managed care terminology in the general concepts of medical insurance (AH-II.1), candidates must recognize that referral authorization, not claims approval or pricing, is the gatekeeper's defining duty.
National insurance concept
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