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A Non-All Inclusive List
By Staff Reporters
There are several key pitfalls to watch out for when evaluating a managed care organization contract, as noted and continually revised by the Advisory Board Company, and others.
- Profitability — Less than 52% of all senior physician executives know whether their managed care contracts are profitable. “Many simply sign up and hope for the best.”
- Financial Data — 90% of all executives said the ability to obtain financial information was valuable, yet only 50% could obtain the needed data.
- Information Technology — IT hardware and sophisticated software is needed to gather, evaluate, and interpret clinical and financial data; yet it is typically “unavailable to the solo or small group practice.”
- Underpayments — This rate is typically between 3 – 10% and is usually “left on the table.”
- Cash Flow Forecasting — MCO contracting will soon begin yearly (or longer) compensation disbursements, “causing significant cash flow problems to many physicians.”
- Stop-Loss Minimums — SLMs are one-time up-front premium charges for stop-loss insurance. However, if the contract is prematurely terminated, you may not receive a pro rata refund unless you ask for it!
- Automatic Contract Renewals — ACRs or “evergreen” contracts automatically renew unless one party objects. This is convenient for both the payor and payee, but may result in overlapping renewal and re-negotiation deadlines. Hence, a contract may be continued on a sub-optimal basis, to the detriment of the providers.
- Eliminate Retroactive Denials — Eliminate the rejection of claims that were either directly or indirectly approved, initially. Sample: “MCO reserves the right to perform utilization review [prospective, retrospective and/or concurrent] and to adjust or deny payments for medically inappropriate services.”
- Define “Clean” and “Dirty Claims” — Eliminate the rejection of standard medical claim formats like CMS-1450, CMS-1500 or UB-92 for non-material reasons. Make payment of appropriate clean claims within some specific time period, like 30 days, in order to enhance free cash flows.
- Reject Silent or Faux HMO or PPs, etc — Eliminate leased medical networks or affiliates and reject further payment discounts to larger subscriber cohorts than originally anticipated.
- Include Terms for Health Information Technology — Eliminate the economic risk of leading edge electronic advancements like EMRs, PHRs, CPOEs, and so on.
- Establish ability to recover payments after contract termination — Eliminate financial carry forward for an excessive period of time.
- Preserve Payment Ability — Provide medical services if requested by patients, who are then billed directly.
- Minimize Differentials — Establish a standardized rate structure [fee schedule] for all plans and then grant discounts for administrative or other efficiencies; rather than have different schedules for each individual plan.
Conclusion
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Filed under: Health Law & Policy, Practice Management | Tagged: Advisory Board Company, Automatic Contract Renewals, “Clean” and “Dirty Claims”, Cash Flow Forecasting, CMS-1450, CMS-1500 or UB-92, CPOEs, EMRs, HMOs, Managed Care Contract, PHRs, PPOs, Stop-Loss Minimums |
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Is Cigna Dental pulling a fast one on dentists?
I received an intriguing call from a Cigna Dental rep today. She offered to direct Cigna’s fee-for-service customers to my practice “even if you are out of network,” with free advertising targeting Cigna’s customers. What’s more, she promised no fee restrictions – allowing me to charge what the market will bear.
Since the offer seemed too good to be true, I patiently awaited the hook. Finally, she mentioned that all that is required of me is to share the profits with my current Cigna PPO patients by giving them “just a little better discount.” Judging from her surprise when I told her that I don’t participate in Cigna or any other PPO plan, I suppose I am one of the very few these days.
Obviously, sales reps prefer relevant leads than to waste time cold calling, making the call this morning seem odd. So I suspect Cigna is conducting a clever ruse intended to enroll more dentists into Cigna PPO plans. If I am correct, could this be a sign that discount dentistry brokers like Cigna are finally having to compete with Delta Dental and other managed care plans for willing dentists?
If there are any Cigna PPO dentists in the audience, I am especially curious to know if you received the same advertising offer. Regardless, what are your thoughts concerning this puzzler?
Darrell
###
Dentists who might be considering Cigna’s free advertisement offer described above should be reminded that nothing is free.
The clever executives responsible for this unfolding scam are awarded bonuses for lowering dentists’ payments – not for treating dentists fairly. Dentists are personally accountable to the welfare of their patients. Cigna employees are not. Cigna’s only obligation is to investors and as long as there is no transparency such as offered in this post, they have nothing to lose.
If I were running Cigna’s scam, and had no ethics, I would have already quietly increased my boss’s market share by signing up more preferred providers at an even lower pay scale than Cigna’s current PPO contracts. Then, shortly before the insurance renewal anniversary for a dentist’s new and existing fee-for-service Cigna clients, I would pull the rug out from under the vulnerable dentist by encouraging his or her patients to switch to a PPO plan their dentist already accepts – at even greater discount than other available Cigna PPO plans.
Like most good scams, this one is beautiful in its simplicity (as long as stoic dentists don’t discuss it with each other).
Darrell K. Pruitt DDS
Editor’s Note: Dr. Pruitt is a practicing Texas dentist. His email address is darrelldk@tx.rr.com
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Appealing Insurance Plan Dis-enrollment Decisions
As a physician-executive, administrator or financial manager, the decision by an HMO or managed care plan to not include your healthcare organization in their plan or network, or dis-enroll you if already included, is not irrevocable.
Despite the above ME-P, you may not have been included, or rejected, because of a number of reasons, including: clinical or economic re-credentialling, malpractice history, unfavorable patient survey, certification, or a host of other tangible or intangible reasons.
Therefore, in order for you to appeal the decision, the following guidelines are suggested in any request for a reconsideration process.
• Obtain a letter of explanation from the medical or clinical executive director.
• Ensure your initial application went through the proper channels of consideration.
• Contact your local plan representative, in person, if possible.
• Make sure your state and national medical affliations are current, as well as hospital and surgical center staffing applications and credentials.
• Write a letter to the medical director and send it return receipt (U.S. mail) or by private carrier.
Inform the director of the actions you are taking to become more attractive to the plan or what you have done to correct the deficiencies that caused your non-inclusion initially.
Good luck.
Dr. David Edward Marcinko MBA CMP™
http://www.CertifiedMedicalPlanner.org
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