One woman’s struggle to overcome HMO blockades

Tips for getting on the inside

Among the elements that have become essential to the growth and success of wound care providers and clinics is membership in managed care networks. The health care environment demands that practitioners affiliate with health maintenance organizations (HMOs), preferred provider organizations, and various hybrid health insurance plans. As more patients enroll in managed care (by choice or corporate fiat), this will become increasingly true. 

But signing on with a managed care plan is not always a matter of filling out a few forms, especially in markets saturated with health care providers. A growing number of plans have closed their doors to new providers, which is a major problem for clinicians who have begun practicing recently. The challenge can be compounded for wound care specialists, because managed care doesn’t, as a rule, consider it a significant area of practice. 

But managed care is gradually waking up to the importance of wound care as a potential financial drain and a growth "industry," says Tamara Fishman, DPM, podiatric wound care consultant at the Primary Foot Care Center and president of the Wound Care Institute in North Miami Beach, FL. Typically, she says, payers don’t approach wound care providers, so the onus falls on clinicians to establish themselves in these systems. 

Fishman, who began a solo practice about three years ago, has had success in convincing managed care plans — even some that had been closed to additional providers — to sign a contract. Here are some tips based on her experiences: 

• Find the relevant managed care plans in your area of practice. Listings may be available at the public library, from state insurance boards, or even, as Fishman found, on the Internet. 

• When new health care plans open shop in your area, contact them quickly and express your desire to become a wound care specialist within their networks. 

• Identify a staff member at the HMO who is instrumental in signing health care providers. Contact him or her with a letter or phone call to express your interest in becoming a network provider. Be sure to stress your expertise in wound care. 

"Not everyone will have openings for you," Fishman warns. Whether they do or not, provide payers with case studies and documentation to demonstrate your facility’s effectiveness and efficiency. "If you believe in your abilities and that they need you, then you need to prove that," she says. 

Fishman occasionally invites representatives from HMOs to visit her office, which often surprises them. It can’t hurt to contact the medical director as well and discuss your qualifications and philosophy of care, she says. When you encounter "closed" managed care organizations, don’t give up; maintain a steady stream of communication to keep them aware of your ambitions. Persistence is crucial, as is patience and a healthy dose of tempered optimism. 

• Know the demographics of your constituency. Such information can be persuasive when lobbying managed care, because it reveals that you are tuned in to your market. "You have to have up-to-date and consistent data to make your case," Fishman says. "For example, if there are a large number of Native Americans in your area, that might be important, because that group tends to have a high number of diabetics and therefore lower extremity ulcers."

Patience is key

• Provide managed care companies with a program manual that describes your primary and ancillary practice capabilities, such as X-ray, physical therapy, and hyperbarics, or your connection to others who provide such services. Present them with a formulary and a sample wound care program. 

"The only way to negotiate a contract with managed care is to have such a manual," Fishman says. "They want to know your capabilities and that you can put together coherent programs and guidelines. You also have to show them that you know when to recommend those services and when to refer a patient to another specialist." 

• Be patient and persistent. Your best efforts are unlikely to yield quick results. Nothing happens overnight with managed care. Fishman says the actions she took a year ago are first showing results today, adding that it often takes HMOs many months before they invite you in. Also realize that payers who have all the health care providers they want may never relent.

Just the beginning

If all goes well and the HMO offers you an application, you’re entering an entirely new — and potentially lengthy and frustrating — bureaucratic process. Before you’re listed as an approved provider, the payer must process your contract, verify your licenses and any board certifications, check references, and confirm the validity of your malpractice insurance. Don’t be surprised if this takes six months to a year. Fishman recommends maintaining regular contact with the HMO in the interim to keep the procedure moving along and monitor delays. If, during the application process, the managed care company changes ownership or merges with another organization, you might be back to square one. "They probably won’t even call to tell you," Fishman says, "so it’s in your interest to keep on top of things." 

Once you’re accepted into the HMO network, push to have your name listed in the approved provider listing as soon as possible. If the next printing is not scheduled for a while, ask to be included on an addendum mailed to members. 

Now prepare for more waiting. Getting listed in a plan doesn’t guarantee that you’ll ever see a patient as a result, Fishman laments, but it’s a first step. "The first hurdle is to be heard, the second hurdle is to become a provider within a network, and the third hurdle is for referrals or patient inquiries to come your way. It could easily be four or five months before people know you’re on the plan and respond." 

Finally, Fishman says, don’t get discouraged if your results are spotty. Her aggressive approach to managed care, while gaining her entrance into at least 10 plans that initially told her they were closed to additional providers, has not been 100% effective by any means. "However, I’m much more successful than I was three years ago," she says.