MAMCO History
MAMCO (the abbreviation for the Mid-Atlantic Managed Care Organization of Pennsylvania, Inc.) is a statewide network which is comprised of multiple regional PPO’s through a signed Affiliation Agreement to increase the marketing potential of each PPO in its approved service area by county. A summary of key elements of the PPO Affiliation Agreement follows:
Purposes The purpose of the MAMCO Affiliation Agreement is the following:
- Genuine coordination of all physicians and hospitals, with a mutual philosophy to manage improved care, rather than simply to manage costs;
- Establishment of appropriate credentialling criteria for physicians and hospitals;
- Utilization review, with direct case management applied to prospective, concurrent and retrospective review; and
- Dynamic, ongoing refinements and enhancements based on system performance, enrollee satisfaction, and objective outcome indices. All decisions relating to medical care and treatment remain ultimately decisions of the physician and enrollee.
-Unless otherwise agreed upon between MAMCO and the underlying PPO, general marketing, medical underwriting, claims repricing, third party administrative services and performance reporting are conducted by the Third Party Administrator OR Payor acceptable to MAMCO.
Steering
-MAMCO agrees that each payor which accesses the network will provide for a financial benefit and/or a financial incentive if a participating provider is selected, unless there is a participating provider referral out of panel or in the case of emergency treatment.
Cooperation
-Each PPO agrees to assist MAMCO in solving problems with physicians and hospitals regarding quality of care, access, billings to members, and compliance with the UR program.
Compensation to Providers
-Each PPO gives MAMCO enrollees access to the favorable rates negotiated with its preferred providers, including enrollees from another PPO in the MAMCO network which utilizes that PPO’s providers5