MCOs dictate what makes a physician’s practice a good bet for a panel
Prettying up your practice for payers
Applying for inclusion in a medical plan is a little like being on The Dating Game. A prospective partner asks you a bunch of questions, and if you are chosen, you win a wonderful prize. But how do you know if you are answering correctly? What is important to an MCO that is checking out new physicians and practices to add to its panel?
"Of course you want [physicians] who are well-trained, board certified, graduated from an accredited program, and have relatively clean malpractice records," says Charles Petersen, CMSC, CPCS, supervisor of physician credentialing at the Health Alliance Plan (HAP) in Detroit. HAP contracts with 3,000 practitioners and covers about 500,000 members in the Detroit/Flint, MI, area. "But you also want to make sure they demonstrate their competence on site."
Petersen, who speaks around the country on credentialing issues, says he never ceases to be surprised by some practices such as the ones with physicians who "run around with sharp instruments," who keep expired medicines on hand because they can be given to the indigent, or the practice that kept the speculums in the dishwasher with the coffee cups.
"There are some rural areas where we have little choice," says Debbie Dexter, manager of provider information and credentialing at King County Medical Blue Shield in Seattle. "You may find one practice which is demanding on price and likes to bad-mouth us in the community." In those cases, Dexter will recruit other providers into that area, creating competition that brings choice to the payer and the public.
Tips for facilitating acceptance
Often, it is the worst practices who are most surprised when they are not accepted into the panel, says Petersen. And as patients become more demanding on service, nonacceptance is growing, he says. So what can you do to put your best foot forward?
1. Don’t balk at the information requested.
Petersen says if a practice, or one of the physicians in the practice, is unwilling to provide any the information required, then the application will be closed.
"We have a rule of all or none, which some people find surprising," he says. "If one physician won’t give us the information we require, then we [will exclude] the entire practice."
There are some basic items, such as copies of licenses, a copy of the malpractice policy, minimum insurance requirements, and information on office wait times, that are required by most payers as part of the application process.
Dexter says she likes to see whatever data are available on practice utilization patterns and outcomes measurements. "I’d find it difficult to believe someone who said they didn’t have any of that data," she says. "Most people know from their work with other payers what their utilization and outcomes information are."
2. Don’t try to hide information.
There are just a few things which can immediately disqualify a practice from being impaneled, says Petersen.For example, King County Medical Blue Shield will immediately terminate any application when a reference doesn’t pan out.
And don’t try to hide your patient records, Petersen says. "You can blind them so we don’t know the names, but we want to know if you are doing what you should be doing immunizations on children, appropriate patient education, and well exams."
3. Don’t fudge your figures.
If you are asked for information on wait times, don’t make them look better than they really are. "We are likely to make a phone call and pose as a new patient to see how long it will take to see us," says Petersen. The nurses conducting the site visits will also ask to see log books and talk to a scheduler.
4. Make sure your charts are legible.
If your charts are on index cards, or if you keep an entire family charted together, you have a problem, Petersen says. "Your records should be coherent and legible. We will have a nurse or physician sit with us and decipher the writing if our site visitor can’t read it."
5. Consider the extras.
There are some things that just make a site visitor think well of you from the start, says Dexter. For example, one of her favorite practices always has patient satisfaction information available for her. "It’s not something we ask for, but if you have it, it’s nice to see," she says.
Petersen mentions practices with outdated reading material in their waiting rooms and furniture that is old, ugly, and uncomfortable.
6. Don’t worry about malpractice.
King County Medical Blue Shield’s application states that malpractice can’t "reflect what in the discretion of the company constitutes a pattern of questionable or inadequate treatment." In other words, says Dexter, if you have a normal career and have had a case or two against you, don’t worry.
7. Don’t think the work’s over once you are impaneled.
Both Petersen and Dexter say problems rarely arise with practices during the application process. It is after that they note difficulties. Perhaps the practice won’t comply with quality assurance programs, or they have trouble getting reports in to corporate headquarters, says Dexter. While she will work with practices on these issues and assist them with whatever training is necessary, there comes a point when the practice will be removed from the panel.
Another problem is patient complaints, says Petersen. Along with bad references, there is nothing that will remove a practice faster from a panel than a string of complaints about it from patients. "We may try to counseling at first, but if that doesn’t work, we have no hesitation in disaffiliating."
• Charles Petersen, CMSC, CPCS, supervisor of physician credentialing, Health Alliance Plan, Detroit. Telephone: (313) 874-7959.
• Debbie Dexter, manager of provider information and credentialing, King County Medical Blue Shield, Seattle. Telephone: (206) 626-6509.
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