Editor's Note: Part I of Dr. Talcott's article appeared in the November 4, 1994 issue of "DC."
Time to Get Credentialed
Another trend in the managed care arena is to redefine a "qualified" provider. This is usually done by raising the standards of credentialing. This typically starts with requiring more documents, pursuing a more thorough scrutiny of those documents, and causing the providers to withstand the scrutiny of verification and validation of those documents, training, professional experience, etc. As an example, instead of simply requiring a license, they also write the licensing board to be certain that it is in effect at that time.
Instead of simply requesting an insurance cover sheet, they will write the insurance carrier to verify that the insurance carrier to verify that the insurance is in effect, and on and on. As fewer people are willing or able to meet the credentialing levels, there are fewer qualified providers eligible to participate in these panels and networks. This is another place that an IPA can be invaluable. By having the credentials of the participants verified, and a system of constant updating of those credentials, the burden and expense is lifted from the managed care company. The burden is often eased for the doctor also.
As the IPA gains contracts with new companies they will often accept the credential documents directly from the IPA. This allows the doctor to avoid submitting all their information to yet another company.
In speaking with Jon Templeton,3 president of Shared Physicians Network, a successful and growing not-for-profit IPA, he states, "While the needs of our SPN participants have remained relatively the same, i.e., access to new patients, the needs of managed care entities have evolved and changed over the past three years. Thus, the managed care entities represent a moving target for an organization like SPN. SPN's primary goal remains fixed: continue to be effective at accessing managed care opportunities for our participants, but remain attentive to the needs, wants and wishes of our managed care clients. This means that SPN must continuously monitor and evaluate this evolving situation and recognize when our services need to evolve, i.e., be updated, and/or adjusted."
Time to Ban Together
The chaos continues. It is becoming increasingly difficult for an individual to effectively access the managed care arena. Especially when some companies are regional while others are national and each want their particular situation handled differently. It's become almost impossible for a private practitioner to undertake this ordeal. Fortunately there is a renewed interest by PPOs and other managed care entities to re-think the use of independent credentialing organizations. These organizations represent a less costly alternative to dealing with credentialing. At Shared Physicians Network, some of the most recent contracts have been secured because a PPO decided to go outside to obtain credentialing and panel administrative services rather than continuing to take those responsibilities.
So what is the ultimate answer for the 1990s?
Get Where the Action Is!
Being from Dallas, Texas and participating in over 40 managed care plans, my experience is becoming quite broad in dealing with many of these issues and I have a few suggestions: 1) Get involved with managed care. It's where the system is headed. 2) Carefully evaluate IPAs that you join. You want your support to go to the strong, legitimate, professional IPAs so that we cannot only catch up with the medical profession's head start on IPAs, but we can join and merge with their IPAs; therefore mutually benefitting both organizations. 3) Be flexible. It's not always going to go your way. This is the era of "let's make a deal." That doesn't mean that you have to accept participation in panels where the PPOs offer ridiculous remuneration schedules, etc., but evaluate each one on its own. Do not participate in those you oppose: participate in those that you feel are reasonable. But remember the more flexible you are, the more patients you will see. 4) Don't get sucked in by groups that have nothing to offer except the ability to extract dollars from you. 5) Stay with an organization or organizations that have size, and are therefore more powerful. At times this helps re-negotiate a fee schedule if a particular company tries to reduce it. It also give other advantages for influencing the inner workings of a particular insurance company. 6) Only join IPAs that allow individual decisions by the physician on whether to participate in each new contract on a one to one basis (i.e., the IPA does not have power of attorney to commit you to anything without your approval ...)
Time to Listen to Others Who Are Knowledgeable
While working with doctors all over the United States, my largest experience is my own backyard, Texas. The following are some interesting quotes from Texans who are in the know about managed care:
Keith Hubbard, DC, chairman of the TCA managed care committee: "In today's health care environment, the very survival of chiropractic in the managed care arena will be based on inclusion in networks."4
Ces Soyring, chiropractic instructor and consultant: "Statistics show that eight out of 10 patients now belong to some type of managed care program in Texas. The frustration I see and hear from doctors and CAs across the state is, 'How do I get into HMOs, PPOs, and then how do we handle all the paper work after our office has gotten the patient?' It appears at this time, that the strongest approach for individual chiropractors to be included in managed care is to join some type of organized network. The sole practitioner can no longer keep up and participate effectively in the managed care arena by themselves."5
Mark J. Hanna, TCA legal counsel: "It appears that managed care, in some respects, is here to stay.6
Phyllis Brasher Esq., health care attorney for Jenkens and Gilchrist, a professional corporation in Dallas: "Having advised numerous medical IPAs and a number of other IPAs, including ones for specialty services such as chiropractic, we are confident that the properly structured networks offer pro-competitive advantages to the health care purchaser and can provide valuable services to the participating practitioners and providers."7
Time to Position for the Future
In conclusion -- a crystal ball look into the future, from Jon Templeton, president of Shared Physicians Network, Inc.
"The future? I foresee all health care providers having increased difficulty with gaining inclusion in managed care programs. The chiropractic profession presently has two areas that need to be addressed for greater inclusion in PPOs and HMOs. Those areas are credential verification and guidelines for case management. The chiropractic profession, as a whole, has no credentialing system. In the medical arena, hospitals credential medical doctors. Through this credentialing process a PPO or HMO often can contract with a hospital and then simply accept into their network the physicians on that hospital staff who are in good standing. In general, chiropractic does not have this available to the profession. SPN provides a credential verification process that follows the standards of accreditation for managed care organizations established by the National Association of Quality Assurance. This rigorous documentation of credentials was originally established for medical physicians applying to HMOs."8
Whatever your future decisions are as a private practicing physician, there is no doubt that more and more people are going to be covered by managed care, be it governmental, private, or both. Your pool of individuals to treat will decrease if you are not involved appropriately.
References
3. Evolving Managed Care Needs, a SPN document.
4. Keith Hubbard, DC, chairman of the TCA managed care committee, "Managing managed care," Texas Journal of Chiropractic, June 1994.
5. Ces Soyring, chiropractic instructor/consultant, ibid.
6. Mark J. Hanna, TCA legal counsel, ibid.
7. Phyllis Brasher Esq., health care attorney, Jenkens and Gilchrist, ibid.
8. Jon Templeton, president of Shared Physicians Network, Inc., ibid.
Ty Talcott, DC
9115 Forest Lane
Dallas, Texas 75243
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