Joining Third Party Networks
Medicare/Medicaid, Blue Cross/Blue Shield, and Other Managed Care Organizations (MCOs)
In their eagerness to get into a managed care system, some doctors do not ask the right questions about managed care participation.
What is Managed Care?
Managed care is a system in which providers, purchasers and patients work together to control costs. It offers patients access to healthcare providers, usually for predetermined fees.
Managed care can include public entities, such as Medicare and Medicaid, and private companies such as Blue Cross. Managed care began more than 70 years ago when American employers began offering health benefits to workers and the need to control costs became apparent.
The creation of Medicare and Medicaid only furthered an explosion of healthcare costs. The current forms of managed care, HMOs and PPOs, were created as ways to manage and curb escalating healthcare costs.
What are the Models of Managed Care?
There are various structures to manage this healthcare. Some models demand rigid adherence to protocols and reduced fees in exchange for a limited number of providers to care for more patients. Other models do not have limited provider networks but require the practitioner to demonstrate clinical necessity for the rendered care. Still others do internal reviews of care by either employed or outsourced reviewers. However, the fact remains that participation in managed care requires the provider and the patient to demonstrate active participation in the process.
If you would like to participate in one or more of the managed care models, please see the traditional managed care concepts outlined below. Keep in mind, however, that managed care models are constantly changing as they are shaped by consumer demand, employer needs and payer requirements. In addition, provider behavior also can shape management models. The basic concepts include:
- Discounting services. Most management methods come down to a negotiation between the doctor and a manager who requests the doctor discount services in exchange for something of value to them. Typically, the doctor may be given the opportunity to gain access to patients via a directory. The doctor must be able to understand and evaluate the relative benefit of these deals and determine if it outweighs what the doctor must give up.
- Defining medical necessity.Management defines and requires the doctor provide evidence for the medical necessity of any services offered. It requires that doctors understand the definitions and the requirements for evidence. This can be difficult to accomplish. Therefore, doctors must decide whether they can provide medically necessary services within the confines of the manager’s definitions and requirements. If they cannot, they may not want to participate.
- Defining scope of practice. As with medical necessity, managers often limit the scope of a doctor’s practice to facilitate management simplicity. The doctor must understand and agree to these limitations to participate in these systems.
What Do You Need to Do to Join the Major Networks?
Many doctors are interested in joining the Medicare/Medicaid (for Medicaid in those states that include chiropractic care) and the Blue Cross/Blue Shield networks. Here are the steps involved in signing up for Medicare/Medicaid and Blue Cross/Blue Shield:
Medicare/Medicaid Provider Number:
- Contract the carrier (varies from state to state) or visit the Medicare website (www.cms.gov).
- Contact your state’s chiropractic association for local Medicaid rules and regulations. (The Congress of Chiropractic State Associations’ website provides links to all state chiropractic associations – www.cocsa.org.)
Blue Cross/Blue Shield Provider Number:
- Most states require that each participating provider have a unique number, although corporations may also need a corporate identification number for filing claims. (Requirements vary from state to state. Check with your state's Blue Cross/Blue Shield office. Locate yours by going to the Blue Cross/Blue Shield website, www.bcbs.com, and entering your ZIP code.)
- Request an insurance filing requirement packet and/or visit with a provider relations representative.
- Request information on electronic billing.
What Should You Consider Before Joining Other MCOs?
In addition to Medicare and Blue Cross/Blue Shield, many D.C.s also wish to join other MCOs. Many major health insurance plans contract with chiropractic MCOs, so there may be significant benefits in joining the right MCO. Keep in mind, however, that some MCOs do not routinely accept new doctors.
For a list of the managed care companies in your area, contact your state insurance department (refer to www.usa.gov for information on your state insurance department). Or your state chiropractic association could provide a listing (refer to www.cocsa.org for a link to your state’s chiropractic association).
But, before you affiliate with an MCO, there are several things to consider about each organization. You might want to call, write or review their website for information. Consider the following about each organization:
What kind of MCO is it?
Each type of MCO operates differently, so it's important to know what type of organization you would be joining. Is it a:
- Health Maintenance Organization (HMO)?
- Preferred Provider Organization (PPO)?
- Independent Practice Association (IPA)?
- Physician Hospital Organization (PHO)?
Does the MCO meet licensure and accreditation criteria?
- Does the MCO comply with qualification requirements?
- Is the MCO licensed by the appropriate agency in your state, e.g., the health or insurance department?
What marketing and service area does the MCO serve?
- Does the plan provide all enrollees with comprehensive information about chiropractic benefits?
- What are the procedures for selecting a chiropractic provider?
- How does the MCO market itself to subscribers?
- Will the MCO provide you with copies of its marketing materials such as brochures,
- posters, etc.?
- How many chiropractors does the MCO contract with?
- Who are the primary care physicians within your area and where are their offices
What contractual relationships are offered by the MCO?
- Does the contract provide for cancellation if you are not satisfied with the arrangements?
- Does the plan have a “hold harmless” arrangement with providers? (This type of clause, frequently found in managed care contracts, specifies that the MCO and physician will not hold each other liable for malpractice or corporate malfeasance if the other party is found liable.)
What Should You Do If Your Initial Application Is Rejected?
If your application to affiliate is initially rejected, don't accept this as the final word. Affiliating with a quality managed care organization may be worth the effort. You can:
- Communicate with the Provider Relations department at the plan.
- Be persistent, professional and non-confrontational. Find others to be your advocate.
- Demonstrate evidence of quality factors in your practice, including credentials, recordkeeping, patient satisfaction, cost-effective outcomes and service- oriented, patient-focused care.
How Do You Stay Credentialed?
One of the concerns of D.C.s is keeping credentialed with an MCO. Credentialing is how the MCO assures a standard of excellence in care. Make sure to stay credentialed by providing the following to your MCO:
- Verification of your education
- Verification of your licensure
- Verification of your malpractice insurance coverage and your history of
- malpractice claims
- Proof of satisfactory completion of educational seminars and self-study courses