Issue 13 - September 2004

Network blues?
Ask the right questions to keep your spirits — and claims — up
By Pat S. Jackson

Chiropractic networks have existed long enough to have more than sufficient data on how the network operates, what impact the network policy has on access to care and how network providers fit in and treat patients. Many doctors of chiropractic find the fit a bit too tight and wonder if the data is solid.

Complaining doctors say that reporting is cumbersome and decisions around patient access to care and services are restrictive. They are shocked to see periodic feedback from networks that label them as outliers and they become frustrated and angry when a network threatens to terminate the contract.

Since these doctors have not changed how they practice, they find network actions unsettling and incomprehensible.

Keep in mind: The network invited you to work with it as a business partner after it reviewed your background and credentials. That process should imply a certain amount of trust between the parties. When you signed the provider agreement, you made a commitment to abide by the network’s requirements and rules, even though some of these rules might not be consistent with your philosophies and practices.

When practice philosophies collide with network policy, the honeymoon ends and trust can potentially erode. To avoid a downhill slide, learn where you stand with the network and how you can take charge of your future. Asking the right questions is the key. Here are some questions to pose:

• ‘Do you have a tier system? If you do, where do I stand?’ Many networks are moving to a tier system that frees doctors from having to pre-certify or gain approval for care decisions.

If your network has a tier system, find out how to interpret the tiers (does tier one provide the highest level of freedom or the lowest?) and on which tier you have been placed. And if you discover you are in a restricted tier, find out why and how to get out of it. (A minor coding situation that could easily be corrected may be placing you in this category.)

For example: Billing a complex E&M code for every patient waves a red flag in front of the insurance company. Ask yourself if you are meeting the documentation requirements of the complex E&M service every time you bill it.

Is your case mix weighted with patients with multiple injuries, co-morbidity or other complications? If this is true, your use of the complex code may be appropriate and this information can be provided to the network. However, if you are using this code for simple, straightforward evaluations, use a less complex code if clinically indicated.

• ‘What type of treatment plan do you require?’ Networks are realizing it's expensive and confrontational to review all treatment requests. In addition, some realize the provider should have an opportunity to execute a positive outcome with the patient. Providing an automatic benefit before the utilization review process kicks in is becoming the norm.

But if you anticipate a difficult patient case management that is expected to extend beyond the automatic threshold, make it known and identify your plan to treat the patient.

Treatment planning is an essential part of patient care and provides a roadmap to measure patient improvement or regression. Do it sooner rather than later to avoid any delays in patient care by asking your staff to come up with a way to identify potentially complex patient care situations. Devise an internal system to execute a notification to the network on these selected cases.

• ‘What is the network's position on providing multiple therapies?’ Is one therapy allowed per visit or are all therapies considered an integral part of a global or per diem fee?

If the network denies multiple therapies, ask for the research that supports the premise that not more than one therapy is necessary.

Before you sign up with a network find out if therapy is a separately billable service. If not, why? What is the network’s clinical mind-set on the use of passive therapies in patient treatment? This same rationale applies to other services such as diagnostic imaging.

• ‘How do you judge my performance?’ Networks use various criteria for measuring data and your patterns of care specifically. Ask what benchmarks you are being judged upon.

Often these may include the number of x-rays per patient, complex code use for E&M and CMT services, passive or active therapy use and whether you provide notification on time.

If you are out of line in even one of these categories, you may be placed in a restricted category. Find out which benchmarks are being used and which one(s) may apply to you.

• ‘Have I been labeled an outlier?’ There is no better way to determine where you stand than to read your own data profile.

Your personal data on how you treat patients may be available online or you can request it from the network. It will allow you to compare your practices to others in your area and perhaps to the entire network.

Unfortunately, providers often do not know how to interpret their data and assume the worst. Just because your data looks different from that of others doesn't mean you have done anything wrong. It simply indicates there is something going on with your patients that may be different than your peers' patients. Identify what that is and tell the network.

Ask the network if they have labeled you an outlier. This means your profile data is significantly different than the majority of other doctors of chiropractic in your area. If this is true, find out if the outlier status requires you to do additional reporting and find out how you can be removed from outlier status.

• ‘What documentation do I need to appeal a claim?’ If you are receiving more denials than approvals, you have a problem. Or, if the network always approves your appeals, ask how you can pre-empt the appeal process.

The network may tell you it needs more specific clinical documentation. Ask officials exactly what documentation is needed. Make sure it is legible and tells a story about the patient — what services were done, why, where they were performed on the patient and what was the result?

The best way to maintain trust with your network is to be open and willing to look at issues from a new perspective. You don't have to agree with everything but you do have to hear people out and vice versa. The quickest way to destroy trust is to become threatening or polarized in some way. Once someone is offended — whether it's you or network staff — the ability to move forward is compromised.

HELP THE NETWORK HELP YOU
Look at the time you invest in the process as education, since it will make the next claim go quicker. Try to determine what the network needs from you rather than to debate the denial. “What information would help you pay my claim?” is far more effective than telling a reviewer he or she is wrong. Knowing where you stand with a network will help you decide if your treatment philosophies are different than those of the network.

If philosophies are radically opposed, this may not be the right network for you or the network philosophy may be too restrictive. Working within a network can be a challenge but you can make it easier if you know where you stand.

Patricia S. Jackson is an insurance expert with more than 20 years of experience. She is vice president of the Office of Professional Development and Research for the American Chiropractic Association and is responsible for bringing the insurance and healthcare professions closer together to develop strategies to control healthcare spending. She can be contacted at 703-276-8800.