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It can happen to the best physicians: You get notice that in 10 days, you will no longer be included as a provider on a managed care panel. How did it happen and what can you do to prevent it from happening again?
"If this represents less than 10% of your patient base, you might not care very much," says Andrea Eliscu, president of Medical Marketing of Winter Park, FL. "If it’s 20% of your patients, you want to get on the phone and find out why this occurred and what you can do to stay on."
To make such a call effective or prevent it from happening in the first place your best bet is to know your provider relations and medical directors at all the plans in which you participate. [See story on developing positive relationships with managed care organizations (MCOs), p. 38.] "Meet with them twice a year, even if you are two hours away from them," Eliscu advises. "Then they know you, your name, and how you are different from other providers."
You should also know your contracts, says Christopher Rolle JD, a partner at Foley & Lardner, an Orlando-based law firm. "Before you sign that contract, know the deselection process. Know what right you have to challenge deselection."
Rolle says that knowing what is expected of you by the MCO can help you to meet their goals and avoid termination. "If they say you have to see patients within a specified time period, then you can be certain of meeting that goal. If you don’t know that rule, then you are more likely to be caught out."
However, most contracts now have a "no-cause clause" that says they can deselect you for no reason, or you can opt out without justification, Rolle says. "It’s akin to at-will employment." But increasingly, in cases where the practice sues over deselection, courts are requiring managed care to provide reasons on why practices have been deselected. "You may not get the contract back," he says. "But you can find out why you were deselected."
Knowing what is in your contract and your rights is a better bet, and a cheaper one, Rolle says. "It’s better to spend $1,500 on a lawyer before you sign the contract to find out what are your rights and responsibilities than to waste your time and money on litigation."
Rolle recommends you make sure that three questions are specifically answered in your contract:
1. How will quality be measured by the MCO, and where do you have to be on that quality scale to maintain your position?
2. How will patient satisfaction be measured and what level of patient satisfaction are you required to meet?
3. What utilization level do you have to meet?
You should also make sure that the process for deselection and any appeals procedures are included in the contract, he says.
If there is a grievance procedure, you may opt to pay a lawyer to walk you through that process while you appeal the termination, Rolle says. You should also make use of your provider relations representatives at the MCO.
"The ultimate hammer is that medicine is a one-on-one relationship between patients and physicians," he says. "If enough patients get mad at the way a payer treats a physicians, then you can move the earth. But don’t rely on that."