MCO Applications: Nine Common Mistakes You Should Avoid

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Author(s): 
By Michael Metzger, DPM, MBA

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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