Managed Care -- When to Join

Editor's Note: Mr. Sherman serves as the executive director of the Congress of Chiropractic State Associations and general counsel for the Ohio State Chiropractic Association.

Every day doctors of chiropractic receive calls from across the country asking them to join a particular managed care group. Some of these organizations are unfamiliar to the doctor, while others have familiar insurance company names.

Generally speaking, doctors are encouraged to get involved in insurance company managed care entities and other well established programs that bear familiar names in the managed care business. Unfortunately these groups have generally excluded chiropractic; patients have had limited access. For that reason, many chiropractic organizations have supported continued expansion into managed care groups as well as proposed legislation that would open these entities to chiropractic.

On the other hand, many of these newer managed care entities are not familiar to the doctors. These organizations are frequently chiropractic PPOs which are attempting to break into the HMO market. They seek money from the doctor in monthly or yearly payments. How should the doctor respond to these groups?

Doctors have looked to their state associations to advise them on the right questions to ask before joining a managed care group, since most associations have refrained from telling their members to join or not join a specific group. There are few managed care organizations that have a sufficient track record to warrant a complete endorsement.

Accordingly, doctors are advised to ask the managed care organization for references before joining. Talk to state association leaders about the organization. Talk to doctors outside of your state who you know to determine the organization's track record. This will tell you more about the organization than a glossy brochure.

Doctors should also ask the following questions of the managed care organization:

1. Does the managed care organization have any current contracts in the state? Outside of that state? How have those contracts impacted the DCs in that state? Ask for references.

    

2. How does the plan conduct utilization review/quality review? Who does it?

    

3. Are there manuals or policy statements mentioned in the contract? Obtain copies.

    

4. Does the agreement apply to workers' compensation and personal injury cases?

    

5. How does the provider receive payment? Is there a fee schedule or does the plan require the provider to accept discounts? Does the plan have the discretion to alter reimbursement or hold back money? Is the fee capitated?

    

6. How does the managed care organization get paid?

    

7. How is data collected? How is the data used?

    

8. Does the organization require adherence to guidelines? What are the guidelines? Who develops guidelines and when are they reviewed? Can the provider obtain a copy?

    

9. How are grievances handled? Is there a right to an appeal of adverse determinations?

    

10. How are providers terminated from the plan -- with or without cause?

     

11. How does the doctor terminate the agreement?

     

12. What services are covered?

     

13. What can the provider do if the organization goes bankrupt? Can the provider bill the patient for money owed?

     

14. Can the organization change billing codes?

     

15. Is there an MD gatekeeper?

     

16. What is the "out of plan" coverage?

     

17. Is there a "hold harmless" or indemnification clause which requires the provider to indemnify the plan for judgments or settlements rendered against the plan for provider negligence?

     

18. Is binding arbitration required if there is a dispute between the doctor and the plan?

     

19. Is the agreement exclusive? Can the doctor join other plans?

     

20. Does the contract contain a "gag" clause which prevents the provider from talking about the group in a negative manner?

     

21. Can the provider advertise that he/she belongs to the organization?

     

22. Are there deductibles and co-pays that the provider must collect?

     

23. Does the plan have adequate liability coverage?

Ultimately, the decision to join a managed care entity is up to each doctor. These questions -- and a call to a knowledgeable friend -- will help make that decision a lot easier.

Rob Sherman Esq.
Columbus, Ohio