Medicare Faqs

What Is a Gatekeeper?
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A gatekeeper is a physician, typically a primary care physician (family practice, internist or pediatrician) who is responsible for determining a patient’s primary services and coordinating the care so that appropriate services are given. In many insurance plans that have networks of hospitals and doctors, the primary care physician is the gatekeeper who provides referrals to specialists.

The Alliance for Health Reform guidebook defines the gatekeeper/care manager as a “Health Care professional, usually a primary care physician, who coordinates, manages, and authorizes all health services provided to a person covered by certain types of health plans. Unless an emergency exists, the gatekeeper generally must pre-authorize referrals to specialists, hospitalizations and lab and radiology tests.” As the medical system moves to bundled payments (where a single fee covers an entire episode of illness from diagnosis and treatment in the doctor’s office to the hospitals and drug usage), the gatekeeper will play an increasingly important role as the overseer of the entire treatment process. There are other systems, called capitated arrangements, where a doctor receives a single, fixed payment for the year for each patient, and must then provide all care for those patients. Some patients will be profitable (total care will cost less than the annual fee), and some will be unprofitable (total spending exceeds the fee). In these, the primary care doctor is the gatekeeper and must work closely with other doctors within the group practice to try to deliver quality care while staying within the capitated fees.
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