MCO Applications: Nine Common Mistakes You Should Avoid

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By Michael Metzger, DPM, MBA

More often than not, we feel like we’re doing the managed care company a favor by applying. There’s also a tendency to believe the process is so cut and dry that we can apply at the last minute. Let’s clear up these misconceptions. If you don’t apply and apply properly, someone else will. Secondly, as our mothers use to tell us, haste makes waste. Indeed, simple mistakes can slow the process down to a snail’s pace and/or cause the company to reject your application. First, I strongly recommend filling out the application yourself. Often, the application will ask for information that your staff may not know. This saves the time of your staff asking you or trying to guess at the answers. Now, as a follow-up piece to the article, “Negotiating The Maze Of Insurance Contracts” (see page 33 of the February issue), let’s take a look at some of the more common mistakes that podiatrists make during the application process. 1. Contracting with the wrong plans or not contracting with the right ones. Deciding which plans to apply for takes some homework on your part. There are many nationally known plans that may not be in your area. Yet there are often smaller, lesser known plans that serve the biggest employers in the area. Be sure to evaluate all the plans that your hospital, referring PCPs and those specialists you refer to are participating in. Also be wary of plans that are served by a single hospital 50 miles away. Many of our colleagues simply sign up for every plan that they can so they can be sure that they never have to say no to a patient. While this is an individual decision, it’s one that may not make good business sense. 2. Requesting an application by phone. Phone messages get lost and often the request for an application has to move from desk to desk. Always make the request in writing. If you want to be able to document the process, ask for a return receipt when you send in your request. Try to learn the name of your provider representative (get the name from a nearby colleague, not the hospital). Give him or her a call and let the rep know you have requested an application. Make this the first step in making an ally of your representative. Avoid Glaring Omissions 3. Leaving blank spaces or omitting key information. The most common omission is the doctor’s signature. Have someone else proofread the application before it leaves the office. Plans want copies of your license, DEA certificate and CV among other things. Be sure you send the current, up-to-date copies. If you need the “additional space,” be sure that any attached sheets of paper are firmly attached to the applications. Staple it two or three times, not just once. Mailrooms tend to lose sheets of paper. 4. Not realizing malpractice history is important. This can be especially troublesome if you have your office manager or spouse fill out this part of the form. They simply may not know everything about your malpractice history or feel that “it is impossible that any patient could have ever been so low as to sue you.” It is suggested that you make a self-inquiry to the National Practitioner Data Bank to see what is on record. You can do this for $20 at www.npdb-hipdb.com. This enables you to ensure that your application matches up with the information from the data bank. Don’t forget to mention pending suits on your application. In fact, this may be another reason why it may be best to complete the application yourself. Let’s face it. To expand this thought, how many of our staff knows all the hospitals we have ever worked at or every malpractice carrier that has carried us? Other Pertinent Points 5. Not reading all the questions on the “yes/no” page. Representatives have told me that one of the biggest problems they see with applications is on the yes/no page. The podiatrists get going with the no answers (no suspensions, no drug problems) and start to simply answer no without fully reading the questions. Just remember that sometimes yes is the right answer. 6. Believing that “they won’t really visit my office.” These insurance plans do send representatives to do on-site inspections and you need to be ready. There is no need to panic if they call the day before or arrive unannounced. Simply assume they are coming. The plan’s representative will want to check out the organization of your office. They will want to review charts to verify that you sign off on every visit, document all services and state allergies clearly, among other things. However, because of confidentiality issues, inspectors should not be allowed to see the name of the patient. I would suggest following the advice of a MD I know. He keeps a small number of charts prepared for blind review. For each visit, he copies the reports and dictation in both. One has the patient name on it (for his records) and the other uses a number which, of course, the reviewer will not interpret (for the review). Go through your charts and have some ready for a blind review. Most plans are very mindful and concerned with confidentiality so they will often usually accept this preparation. Review your OSHA, CLIA and HIPAA materials. Put your staff on guard. Sometimes, the plan will use a secret shopper to evaluate the operation of your practice. Remember that if you want to stay ahead on this, you can ask a family friend to come to your practice as a patient to give you feedback. 7. Not following up. Find out how long the credentialing process takes. Often, the plan will only review applications once or twice a year. In those cases, calling every month to see if you were approved is a waste. However, it is a good idea to monitor monthly if the plan has received the needed information from other sources. Do not nag the representative. He or she cannot do much to speed up the process. 8. Failure to plan ahead. If a new associate will join your group soon, get an application rolling for that doctor long before he or she arrives. The same holds true for re-credentialing. Most plans update their files every few years. The application they send then is different from the first one. Plan to file the renewal application well before the deadline. 9. Accepting a rejection without question. Don’t take “no” lying down. Plans don’t have to tell you why you were rejected but many will, especially the plan’s representatives. Check to see if you can appeal. Dr. Metzger is the founder and principal of Innovative Healthcare Resources, which provides practice management information and consultation, and locum tenens to the podiatric community. For more info, you can contact Dr. Metzger at (800) 495-8959 or via e-mail at mzmetzger@attbi.com. You may check out www.innovativehealthcareresources.com.

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