How a hospital, a physician network, a medical group, and an IPA fit together

These are different names. A Medicare decision in Los Angeles County depends on which of them your care actually uses.

A hospital is one building. Medicare keeps a record for that building.

A health system is the organization that runs more than one hospital, or the name people use for a hospital and its doctors. A plan can include one building and not the others.

A physician network is the doctors affiliated with a hospital or a system. It is not the building. A doctor in that network can be in a plan that does not include the hospital, and the hospital can be in a plan that does not include that doctor.

A medical group is doctors who share an administrative structure. On many Medicare Advantage HMOs, that group handles referrals and prior approval.

An IPA, an Independent Practice Association, is independent doctors who contract together. In this county, people often use “medical group” and “IPA” for the same assignment. The plan is still the insurance contract. It is not the hospital, the physician network, or the group.

City pages name the hospitals, groups, and referral paths people in that city use. This page is the explanation. Ask the office which group your doctor uses this year, which hospital that group uses, and which plan includes both. Then check the same names on Medicare.gov.

Start with the care you already use

The plan and the medical group are two different choices. The questions in My Medicare Checkup are the list to take to the office. Keeping your doctors is the same check in a longer form.

  • Which doctors or specialists do you want to keep?
  • Do you want a wider set of specialists, or a smaller group that coordinates more of the care?
  • Which hospitals do you prefer?
  • Have referrals or access been a problem before?
  • Do you want more care coordination, or more freedom to see doctors outside one group?

If a referral was denied

In California, the medical group often makes that decision. A different group can mean different specialists and a different way of handling referrals. It does not undo a deadline already on a denial letter. You still have the plan’s appeal process. Ask the letter who decided and when an appeal is due.

Changing a medical group

You can sometimes change your medical group when you enroll in a plan or during certain enrollment periods. Changing the group can change which specialists you can see and how your care is coordinated. Changing the group and changing the plan are not the same step. If you want the doctors, the hospital, and the group looked at together, Talk with Alan.

The words behind the split

You do not need these words to use the page above. They are the names for the same split. A Medicare Advantage plan has to arrange a primary doctor, specialists, care coordination, prior approval, claims, quality reporting, and the diagnosis codes Medicare uses to pay the plan. In many states the plan does those jobs itself. In California, plans often delegate some of them to a medical group or IPA. That is why a denial letter can come from the group, and why two neighbors in the same plan name can have different referral rules.

What is a medical group

A medical group is doctors who share an administrative structure. The name on the card is not enough to know who approves a referral. The four patterns above are the usual Los Angeles County split. The contract can differ.

What is an IPA

An Independent Practice Association is independent doctors who contract together with health plans. In California an IPA is often the medical group you are assigned to. On a delegated contract it can do work people expect from the insurance company: prior approval, routing a referral from the primary doctor to a specialist, credentialing, care management, quality reporting, and sometimes paying the doctors’ claims. That is why people say “my medical group denied the referral” instead of “my plan denied it. ” The plan is still on the contract. You still have the plan’s appeal rights.

What is delegation

Delegation is the plan formally handing some of its Medicare Advantage jobs to the group. A contract can include some of these and leave others with the plan. Ask which ones apply before you rely on a general rule.

  • Prior approval and medical-necessity review.
  • Referrals from the primary doctor to a specialist.
  • Claims payment to the doctors in that group.
  • Credentialing.
  • Care management for chronic illness.
  • Quality reporting and the diagnosis coding Medicare uses to pay the plan.
  • Which specialists are available inside that group.

Capitation is the usual payment

On many delegated contracts the plan pays the group a set amount per member per month, called capitation, whether that member uses a little care or a lot. The group then manages the care inside that amount. That can push a group to invest in prevention and follow-up. It can also push a group to narrow specialists or slow an approval. Neither result is guaranteed. Capitation is not your premium, and it is not a copay you can look up on this page.

What you notice

If the group is not delegated, you usually call the plan about a referral, a claim, or a grievance. If it is delegated, you usually call the group about the referral and the authorization, and the group may be the one that pays its doctors. People say they want to switch medical groups. That can be a change of group inside the same plan, or a change of plan. Those are different steps. This website does not do either one.

Names in Los Angeles County

The names in each pattern above are the ones people ask about. A name with no label on the ZIP list was not in the local index. The ZIP list shows which of these names have been observed near you. It is not proof your doctor is in the group.

Wanting a hospital is a separate question

Wanting USC, UCLA, Cedars-Sinai, or City of Hope means you ask whether that doctor, at that address, is in that plan this year. Being comfortable with Optum, Regal, Lakeside, or Allied Pacific is the same kind of question. Write down the hospital and the medical group with the My Medicare Checkup. If you want that hospital and that medical group lined up with the doctors you already use, Talk with Alan.