Quality Care Partners - FAQ

Frequently Asked Questions

Quality Care Partners (QCP) is a provider organization (PO), created in 1995. Over the years we have continued to grow to create a premier provider network in Ohio. Along with Provider Network services we also provide a complete range of healthcare benefit management services including Utilization Management, Disease Management, Case Management, Pharmacy Program, a 24-hour Nurseline and Wellness Programs.

No. QCP is not an insurance company. Your health insurance carrier works with QCP to give you access to a comprehensive network of physicians, hospitals and ancillary healthcare providers for your healthcare needs. Using a QCP provider makes the healthcare services you receive cost less, thus reducing your out-of-pocket expense. QCP may also provide other medical management services through your health plan. These services may include utilization review (pre-certification), case management, pharmacy program, disease management, nurserline and wellness programs.

Check the back of your medical ID card for information on services provided to you by QCP, or call us at 740-455-5199 and we will be happy to assist you.

Call the provider’s office or us before you schedule a visit to confirm the provider’s participation in QCP. You can also search our on-line provider directory, check your health plan card for the correct logo to search by. Please keep in mind that if a provider participates with QCP at one office location, it does not mean that all of his or her office locations also participate. Provider participation may be location specific.

QCP's Customer Service Department can be reached at 740-455-5199, Monday – Friday from 8:00 AM to 4:30 PM to help assist you with finding a provider in the QCP Network.

Let your physician know that you use the QCP network. Ask if he or she would consider joining. If they are interested, advise them to contact the QCP Credentialing Department at 740-455-5199 and we will be happy to assist them.

You may use any provider, but you may have a financial incentive to utilize the QCP network. For example, lower coinsurance payments are typical when you use providers within the QCP network. Refer to your plan document for out of network benefit information.

First verify the provider is participating in the QCP network by calling your provider or contacting us at 740-455-5199. Review your eligibility and coverage guidelines determined by your insurance carrier before seeking treatment. Next, schedule your appointment. Remember to show your medical ID card with the QCP logo when you visit the office.

First, check your benefit levels for using QCP providers. Next, call the provider, tell them you are a QCP participant and confirm they are participating with QCP. Schedule your appointment. Be sure to show your medical ID card with the QCP logo at your visit.

Be sure you understand your benefits and costs before seeking care. Your individual plan may require co-pays and/or deductibles, even though they are in-network. These costs are often substantially less than going to an out of network provider. You are responsible for all costs not covered by your healthcare plan.

Please be prepared to pay any copays at the time of service.

QCP is a medical provider network and medical management company. We do not determine or verify eligibility or any benefit levels. Your insurance plan determines which services are covered, and at what levels. Please refer to your certificate of coverage provided by your health plan or contact customer service by calling the number on your medical ID card. Patients are responsible for payment for non-covered services, deductibles and coinsurance.

If QCP is listed as the medical management company on the back of your ID card, QCP can assist you with pre-certification and ongoing care management coordination. QCP can answer your questions and clarify your options before you incur any costs. Additionally, we can help you understand when you should call your insurance carrier. We can also assist with questions regarding the network and help you find a provider. You can contact us Monday through Friday 8:00 AM to 4:30 PM at 740-455-5199 or via e-mail at info@qualitycarepartners.com.

In addition to the QCP Network, QCP provides a wide range of medical management services including utilization review (pre-certification), case management, disease management, Healthphone, a 24-hour nurseline, pharmacy benefit management (QCP Rx) and wellness programs.

Under your group health plan, you are free to decide whether to use a QCP provider, but there are many advantages to doing so:

  • They will file health insurance claims for you.
  • They will collect only patient co-payments and/or coinsurance, not the full amount of the charges.
  • Your out-of-pocket expenses will be less.
  • They will not balance bill you for charges above UCR (Usual Customary Reasonable) charges.

In an emergency, always seek medical care immediately. Go directly to the nearest emergency facility or call 911. An emergency is an accident or sudden illness that a person with an average knowledge of medical science believes needs to be treated right away or it could result in loss of life, serious medical complications or permanent disability.

Some examples of emergencies could include:

  • Seizure or loss of consciousness
  • Uncontrolled bleeding
  • Inability to breathe or shortness of breath
  • Poisoning or suspected overdose of medication
  • Chest pain or oppressive squeezing sensation in the chest
  • Numbness or paralysis of an arm or leg
  • Sudden slurred speech
  • Broken bones
  • Severe pain

Your plan may require that you contact QCP within 48 hours of an Emergency Room visit to pre-certify your visit. Please refer to your plan document for details on pre-certification requirements for ER visits.

These are physicians who identify themselves as Family Practice, Internal Medicine, or Pediatric doctors. A primary care physician (PCP) is the physician you should establish a relationship with so you have a 'medical home'. A medical home can assist you when you are acutely ill as well as perform annual physicals to identify any conditions you may have. Please check with your human resources office or plan administrator to clarify the specifics of your health plan. The plan administrator's number is located on your medical ID card.

If you need to find a primary care physician in your area, please use our Provider Search. If you have difficulty establishing with a primary care physician, please contact QCP. Our staff is here to assist you.

A co-payment (co-pays) is a designated dollar amount paid by the insured to receive specified services. This is payable at the time of service. Some plans require co-pays for doctor visits, prescription drugs and emergency room visits. Co-payments are separate from the deductible amount and normally do not apply toward the annual deductible. Additionally, the deductible does not usually need to be satisfied before a co-payment applies. Please refer to the Summary of Benefits provided by your health plan for specifics of your health plan.

Coinsurance is a cost-sharing requirement under certain health insurance policies. It requires the insured (patient) and the insurer (the employer or health plan) to pay a portion or percentage of the costs for covered services. For example, a plan with an '80/20' coinsurance design would require the employer to pay 80% of the allowable and the patient to pay 20%. Please refer to your plan document for your actual benefit.

The deductible is the amount of money an insured needs to satisfy after making a claim before their insurance company provides benefit coverage. With health insurance, deductibles usually range from $500 to $5,000. So if the insured has a $1,000 deductible, for example, and has a $10,000 claim, he/she will be responsible to pay $1,000 before the insurer starts paying coverage.

The out-of-pocket maximum is a predetermined limited amount of money that an individual must pay out of their own pocket, before an insurance company will pay 100 percent for an individual's health care expenses.

UCR stands for Usual, Customary, and Reasonable – the maximum amount allowed for a covered service based on the following criteria:

  • UCR may be limited to the customary charge based on the distribution of charges billed by all providers for a given service within a given specialty and geographic area.
  • UCR must also be reasonable to the insurer with respect to customary charges for services of comparable complexity and difficulty.
  • The advantage to using QCP providers is that you will not be billed for the balance above UCR, what the insurer allows or pays and the provider bills or charges.

Yes, however your benefits may be reduced as a result which will mean more out-of-pocket expense for you. Because QCP does not pay your claims or have access to information about your benefits and eligibility, contact your insurance company or your claims payor directly regarding how this will apply to your policy. That phone number should be on your insurance card or you may contact your human resource office where you work.

A preferred provider is a prescreened doctor, hospital, or other healthcare provider who has agreed to offer their services at predetermined rates. QCP has developed a comprehensive network to supply you with multiple specialists of medical care.

A physician or other provider has an agreement with QCP to participate in the contracts QCP holds. These providers agree to comply with utilization and quality processes to assist you in coordinating your care.

Costs are lower for covered services in the Network for the following reasons:

  • Participating providers agree to negotiated fees or discounts.
  • You are not balance billed for the difference between the negotiated fee and the actual charge.
  • Your share of the cost for medical service and co-insurance is lower for services rendered in the network because through the discounts QCP has negotiated it will cost your employer less money.

A brand-name drug is usually available from just one manufacturer with a patent on that drug. Generic drugs have the same active ingredients and mechanism of action as the brand equivalent, but are produced only after the brand name drug’s patent has expired. Often, you will have a lower co-pay which means less money out of your pocket by using generic drugs whenever possible.

A formulary is a list of brand name and generic medications that have been reviewed and selected by a committee, which is made up of practicing doctors and clinical pharmacists. If your pharmacy benefit includes a formulary, you can save money by encouraging your doctor to prescribe medications from this preferred list.

Brand-name drugs are more expensive than generics because the manufacturers have spent years on research and clinical studies in developing a new medication. As a result, drug manufacturers look to recover some of these research and development costs through drug pricing strategies. Because there are no drug price controls, manufacturers can set the price of their drug at whatever level they want.

However, once a patent on a brand-name drug expires, generic manufacturers may produce an equivalent generic drug. Because generic drug manufacturers are not introducing a new drug, they avoid the related expenses associated with developing a new medication, which is reflected in the lower price.

There are many myths and misconceptions about generic drugs. Some people believe that quality is tied to costs, and that a less expensive product is of lower quality. In the case of generic drugs, that is simply not true.

A generic drug can be produced once the brand-name drug patent has expired. However, the Food and Drug Administration (FDA), which approves brand-name drugs, must also approve all generic drugs before they can be sold. To gain approval by the FDA, a generic drug must:

  • Contain the same active ingredients in the same amounts as the brand-name drug.
  • Be identical to the brand-name product in dosage form and in the way it is administered. For instance, if a brand-name drug is a tablet taken by mouth, the generic must also be a tablet taken by mouth.
  • Have the same uses, cautions, warnings and product labeling as the brand-name drug.
  • Have absorption rates that closely match that of the brand-name product. In other words, the time it takes for the body to absorb the generic drug and the amount absorbed at a given time interval must be nearly identical to the brand-name drug.
  • Meet batch consistency requirements for identity, strength, purity and quality. Each batch of the generic drug must be identical in every way to all other batches of the generic and brand-name product.

A generic drug must contain the same active ingredients in the same amounts as the brand-name drug. However, the inactive ingredients, as well as the color or shape of a generic drug, may be different from its brand-name counterpart.

Individuals who are experiencing a 'reaction' to a particular generic drug may be allergic or sensitive to these inactive ingredients or dyes. Switching to another product from a different generic manufacturer may relieve the problem.