Are MCOs making your life miserable?

Develop a positive relationship with payers

Nearly half of the respondents of the 1996 Physician Marketing & Management reader survey said their biggest problem is the increasing number of requirements put on them by managed care organizations (MCOs). In individual conversations, the readers report varying problems, such as documentation that used to be done by insurance companies being foisted on overworked practice staff or referral requirements that are too onerous or even harmful to patients.

Nearly all of those to whom PMM spoke feel their relationship with MCOs is increasingly adversarial. But according to some managed care executives and physicians, there are some simple steps you can take to create a positive working relationship.

"When we physicians are taught, we are taught to be competitive, not collaborative," says Edward Cabrera, MD, MBA, FAAFP, medical director of American Medical Healthcare of Orlando, FL, a new HMO owned by American Medical Securities of Green Bay, WI, that currently covers 3,000 lives in the Orlando and Jacksonville areas. "We have to change our attitudes from a win/lose mentality to one that recognizes you can have a win/win scenario."

Cabrera says the easiest and most important step in creating that win/win relationship is to get to know the medical directors of all the plans with which you work. "If you have a problem getting a referral and you call the main switchboard number to lodge a complaint, that complaint can get lost in the shuffle," says Cabrera. "If, on the other hand, you call the medical director directly, the complaint will go farther. It is a very effective tool."

You should be on a first name basis with the medical directors of all the plans with which you contract, he says. "If there are cuts to be made in providers, the director is going to think of the physicians he knows, whose work he knows, and be less likely to cut them."

Harriet Wallsh, RN, director of provider relations at CIGNA HealthCare Florida in Orlando, agrees that knowing the medical director is a good first step. "Doctors are skeptical of us when we say we want to be a partner, but it is not in our interest to have poor relationships, either."

You should also get to know your provider relations personnel, she advises. "They are your advocates, too. It is their job to help you through the processes, to guide you through appeals, or tell you what the next step is if you are not happy with a decision."

Similarly, you should make sure that the provider relations staff know who they can contact in your office if they have questions for you. "Personal relationships help to make everything run smoother," Wallsh says. "Knowing who we can talk to and who you can talk to, makes for a better fit."

Part of the problem is that many physicians don’t know what is in their managed care contracts. Mervyn Shalowitz, a physician with The Medical Care Group of Skokie, IL, worked for 14 years as a medical director of United Health Care in Chicago.

Both Wallsh and Shalowitz agree that knowing such basics as the rules of referral are key to building a positive relationship with an MCO. "Many physicians never ask to see their contract," Shalowitz says. "But anyone who has managed care patients has to know the terms they work under. They should have a copy, they should read the contract, and ideally, they should have legal advice about it before it is signed."

Shalowitz and Cabrera say one of the best ways to ensure that the managed care organization is run with patients in mind is to become involved in management. "All plans are starting to go for accreditation by the National Committee of Quality Assurance (NCQA)," Shalowitz says. "They have to have physician involvement to get that certification."

Cabrera says that most plans are crying out for physician representation on various committees, including quality improvement and credentialing — two which can have a direct impact on the care provided to patients. Most of these are paid positions, about $75 to $100 per hour with meetings held early in the morning or late in the evening.

Shalowitz suggests calling those plans where you get the bulk of your patients. Many of those plans may also need medical directors or associate medical directors, he says. "Sometimes, these are part-time positions that allow you to keep practicing." n

The following are names and telephone numbers of sources quoted in this issue.

Medical Group Management Association, Englewood, CO; Andrea Rossiter, vice president for professional development. Telephone: (303) 799-1111.

American Medical Healthcare, Orlando, FL; Edward Cabrera, MD, MBA, FAAFP, medical director. Telephone: (407) 660-1611.

The Medical Care Group, Skokie, IL; Mervyn Shalowitz, MD, physician. Telephone: (847) 677-4200.

CIGNA HealthCare Florida, Maitland, FL; Harriet Wallsh, RN, director of provider relations. Telephone: (407) 875-7771.

Sullivan/Luallin, San Diego, CA; Meryl Luallin, chief executive officer. Telephone: (619) 283-8988.

Professional Management and Marketing, Santa Rosa, CA; Keith C. Borglum, vice president. Telephone: (707) 546-4433.

ADF Medical Practice Development, Germantown, TN; Alan Flippin, president. Telephone: (901) 758-1963.

Hattiesburg Clinic, Hattiesburg, MS; Theresa Erickson, CME, assistant administrator. Telephone: (601) 268-5869.

Neil Baum, MD, physician, New Orleans, LA. Telephone: (504) 891-8454.

Provider Solutions, Kensington, MD. Telephone: (301) 933-2223.

Mainstreet Software, Sausalito, CA. Telephone: (800) 548-2256.

Medical Marketing, Winter Park, FL; Andrea Eliscu, president. Telephone: (407) 629-0062.

Foley & Lardner, Orlando, FL; Christopher Rolle, JD, partner. Telephone: (407) 423-7656.

Browne-McHardy Clinic, Metairie, LA; Bob Goldstein, FACMPE, chief administrative officer. Telephone: (504) 889-5218.

Murfreesboro Medical Clinic, Murfreesboro, TN; Donald Lloyd, FACMPE, chief executive officer. Telephone: (615) 893-4480.

Associated Colon & Rectal Surgeons, Plainfield, NJ; Craig Marshall, CMPE, CHE, CMM, practice administrator. Telephone: (908) 756-6640.

Healthcare Midwest, Kalamazoo, MI; Craig Stoner, chief executive officer. Telephone: (616) 373-4646.