Managed care: From stress to success
By Debra L. Southard

It started as a way to provide high quality healthcare to consumers, while containing costs to businesses that provided healthcare coverage to employees. But managed care has evolved into a billion dollar burden that businesses, patients and providers all have to shoulder.

What’s the best way for you to cope with unwieldy co-pays, deductibles and types of services allowed by the myriad of plans? Here are five strategies to turn managed-care stress into managed-care success.

STRATEGY #1: GET CREDENTIALED

Joining a managed-care organization (MCO) is not a casual process, nor is it one that should be done with little thought. Becoming credentialed by MCOs involves three steps: selecting the managed-care organization(s) in which to participate, getting approved and dealing with a rejection.

• Selecting a managed-care group. Remember that it is your choice to participate in a managed-care organization. And many doctors choose not to participate, depending upon their location, the demographics of their patient population and how they decide to bill for services rendered.

If you want to become part of a network, make an informed decision by asking the right questions, such as:

• “What chiropractic services does your plan cover?”
• “What is the coverage (by percent) for each service rendered (such as therapy, adjustments, etc.)?”
• “What are your frequency limits? ”
• “How many visits do you allow for adjustments, therapy and other services?”
• “Do visits to other doctors (such as MDs or DOs) take away from the total number of visits allowed?”
• “Is pre-authorization required? If yes, can I obtain permission by phone or do I have to get it in writing?”
• “Do you require a referral from the patient’s primary care physician?”
• “Can I treat a patient out of network if the primary will not refer? ”

• Getting approved. Physicians who apply to become part of a managed-care network must meet the organization’s qualifications, which increasingly include quality and cost-effectiveness standards. Managed-care organizations conduct exhaustive investigations into qualification to assure that applicants meet all of their standards. Some companies even visit your office for a site inspection.

The approval process takes from two weeks to six months, depending on the company. Once approved, physicians must become re-credentialed on a regular basis. Each individual doctor must have a provider number, and a clinic with multiple doctors must have a group number.

• Dealing with denial. Several things can abort your attempt to join a network, such as having been sued by a patient for wrongful treatment, a disciplinary action by the state chiropractic board for fraudulent billing or too many providers of your type in your geographic area. Address any of these issues up front.

If, however, an MCO denies you because of the number of chiropractors in the local area, ask for a list of all chiropractors in their plan. You can use the list to refer patients to these physicians. But actually, you can use the list to fight the denial, since most managed-care companies allow 20 times more MD/DO physicians than chiropractors in their programs.

STRATEGY #2: MANAGE TREATMENT

Improper treatment plan management is a red flag to insurance companies. For example: If a patient is scheduled for treatment three times a week for four weeks and he misses several appointments, the insurance company may infer that you are not helping the patient in a timely manner.

Manage the treatment plan by educating patients about the importance of following the plan (and the consequences of not doing so); documenting missed appointments; and notating on patient records, “progressing as expected” or “due to patient non-compliance with treatment plan, progress is slower than anticipated.”

STRATEGY #3: PAYMENT STANDARDS

Co-payments from patients are usually between $5 and $20. To be in compliance with your provider contract you must collect co-pays and deductibles. The most problematic yet preventable mistake practices make is to allow patients to run the office. This occurs each time you ask for payment and they respond, “I forgot my checkbook” or “I will pay you next time.” It also happens when patients leave without having their next visit scheduled.

Collections will be higher and you will remain in compliance with MCOs when your patients know about their financial obligations and are held accountable for payment.

STRATEGY #4: FIGHT BACK

The most common MCO denial is “Not medically necessary.” Accepting this denial is a mistake. When a claim is denied because it is “not medically necessary”:

• Ask why it is not medically necessary;
• Ask for the basis of the denial. The MCO must provide you with an exact clinical determination along with its logic that led to that determination.

The more claims you fight, the more the MCO realizes you know how to fight back.

Realize that fighting denials is not about the money. You can always bill the patient, but statistics show that when the insurance denies and the patient must start paying, the drop-out rate for care increases.

STRATEGY #5: SHOW IMPROVEMENT

The most effective tool you have in your managed-care tool bag is documentation. Keep meticulous notes about patient care and improvement. MCOs are willing to pay for treatment that is necessary. But the only way they know the necessity is by the documents that are provided.

Make sure you document:

• Gaps in treatment. If these are caused by patient non-compliance, document missed appointments. Discuss the problem with the patient. See if you have gaps in treatment caused by patient non-compliance.
• Patient progress. Indicate if the patient is improving and why.
• Detailed documentation. Each component of care must be documented in detail.
• Follow-up exams. These provide comparative data to justify further treatment.

Train your staff in proper documentation guidelines. They clinically interact with modalities and x-rays and responsibilities in the documentation process.

Managed care is an element of healthcare that causes patients and providers a great deal of stress. You can deal with managed care if you have a team with strong follow-through skills, effective procedures and a clear understanding of what each insurance company requires for compliance.

Debra L. Southard serves as the director of education for ChiroMecca, which offers nationwide certification programs for chiropractic assistants. She can be contacted by calling 888-236-3222 or by e-mail at cen@bright.net or through the company’s Web site www.chiromecca.com.