Ask these questions before signing a managed care contract

Ask these questions before signing a managed care contract

Sherman, Robert P

Reprinted with permission from The Best of the Best compiled and edited by Robert P. Sherman, Fig., and C. Jacob Ladenheim, Edg.

Every day, attorneys receive (calls from doctors asking if they should join a particular managed care organization (MCO). Some of these groups are unfamiliar to the doctor, while others have familiar insurance company names.

Generally speaking, chiropractic associations encourage doctors to get involved in insurance company MCOs and other well-established programs that bear familiar names in the managed care business. In the past, these groups have generally excluded chiropractic. Although patients still have limited access, we are seeing more and more managed care organizations include chiropractic doctors due to patient demand.

As a general rule, doctors should be leery of chiropractic organizations that ask for money up front to form a chiropractic MCO. These new groups frequently have no track record. Newly formed MCOs that have little money and no “big name” backing are likely to fail.

Before you sign on the bottom line, the best advice a chiropractic association can offer is to ask for references. Talk to state association leaders about the organization. Talk to doctors you know outside of your state to determine the organization’s past track record. This will tell you more about the organization than a glossy brochure.

Speak to as many doctors as you can before making a decision. You should question the legitimacy of any MCO that refuses to provide this information.

Other questions you should ask include:

1. Are there manuals/policy statements discussed in the contract? Ask for copies.

2. What health care program does the agreement apply to? Are workers’ compensation and personal injury included?

3. How does the managed care organization get paid?

4. How do you get paid? Is there a fee schedule or are discounts applied? Does the MCO have the discretion to alter reimbursement? Can it hold money? Is the fee capitated?

5. How are utilization review/quality review programs conducted? Who does the reviews? Is there a right to an appeal of adverse determinations? (Under the workers’ compensation system, there are two levels of appeal. A DC must conduct the review of another DC at one of these levels.)

6. What policies govern the reporting of data? (If you are not electronically able to transfer information-including fee bills-you should do everything necessary to get online NOW.)

7. Does the organization require adherence to guidelines? What are the guidelines? Who makes them? Can you get a copy?

8. How can a provider be terminated-with or without cause?

9. How do you terminate the agreement? (Where you have questions about an agreement, look for short termination provisions.

This allows you to try out the program for short periods of time before fully committing.)

10. What services are covered?

11. What do you do if the organization goes bankrupt? Can you bill the patient? (Most agreements require you to KEEP TREATING even if the MCO goes bankrupt.)

12. Can the organization change your billing codes? (The changing of billing codes is a national problem. Eventually, a court will have to determine the legality of this insurance practice.)

13. Is there an MD gatekeeper? (As a market matures and the providers are better known to the MCO, the gatekeepers system starts to erode. Consumers hate this type of system, and the insurance carriers are responding by expanding access and removing gatekeepers.)

14. What is the “out of plan” coverage?

15. Is there a “hold harmless” clause? (Consider sending the hold harmless clause to your malpractice carrier. If the clause is written so broadly that it requires YOU to defend the carrier from the carrier’s own negligence, your malpractice insurance will not cover that event.)

16. Is binding arbitration required? Mediation? (Mediation is the best way to resolve disputes. Mediation is voluntary, and the participants decide the results. You will see more and more disputes resolved in health care using mediation.)

17. Is the agreement exclusive?

18. Does the contract contain a gag clause? (Most legal observers agree that it is illegal to prevent you from speaking frankly to patients about terms of the agreement that could negatively impact on care. Most carriers have removed these onerous provisions.)

19. Can you advertise that you belong to the organization?

20. Are there deductibles and co-pays that you must collect?

21. Does the plan have adequate liability coverage?

22. Does the managed care organization have any current contracts in the state? Outside of that state? (This is a critical question if the MCO is new to you or does not have “big name” backing.)

Ultimately, the decision to join a managed care entity is up to each doctor. These questions-and a call to a knowledgeable friend– will help make that decision a lot easier.

Robert P. Sherman, Esq., practices in Columbus, Ohio. C. Jacob Ladenheim, Esq., practices in Fincaste, Virginia.

Copyright American Chiropractic Association May 2000

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