What is a typical function of third-party payers in managed care systems?

• A. They require patients to pay entirely out-of-pocket with no review.
• B. They monitor services to avoid overuse and may use gatekeepers to manage access.
• C. They promote unlimited access to specialists without referral.
• D. They do not contract with providers.

Answer: (B)

In managed care, third-party payers act as cost controllers by overseeing how care is used and by gating access to services. They review requests for tests and procedures to determine medical necessity, and they often require referrals and preauthorization before certain services or admissions are approved. This gatekeeping helps prevent unnecessary care and coordinates overall treatment within a negotiated network.

The other ideas don’t fit typical managed care dynamics: requiring patients to pay everything out-of-pocket with no review bypasses utilization management; enabling unlimited access to specialists without referrals removes gatekeeping; and not contracting with providers would unravel the network and undermine managed care pricing and access controls.