How ED Physicians Can Protect Their Turf
Emergency physicians need to play a bigger role in the future of emergency medicine under managed care, notes Alan Forstater, MD, assistant clinical professor of emergency medicine at Thomas Jefferson University Hospital in Philadelphia.
"Up to now, we’ve been sheltered from direct communication with health plans. But that will have to change as managed care also undergoes change," Forstater says.
Emergency physician groups need to adapt quickly, adds Joseph E. Clinton MD, chief of emergency medicine at Hennepin County Medical Center in Minneapolis. Here are some strategic suggestions for protecting your turf against the uncertainties of environmental flux:
• Learn what’s in your provider agreement. Unfortunately, health plan contracts are far from standardized, Forstater says. That’s why it’s imperative that emergency physicians understand pertinent details that limit the ED’s powers and liabilities. How do you do this? Take the time to read the fine print, states William Hanna, chairman of The Pilot Group, a Pittsburgh-based managed care consultant.
• Build ties and offer input to hospital management. Your hospital’s director of managed care can be your strongest ally. But it’s even more important to let administration know that the medical staff is keenly interested in the future of the ED, says Hanna. "Meet with the CEO," he advises.
• Look for long, stable contract terms. During a health plan merger, it’ll be business as usual regarding preauthorization and medical necessity issues. But all bets are off in the aftermath unless you stipulate contingencies in the event of a merger, Hanna says. Hold the original payer to a long-term contract, usually between three to five years, he adds.
• Write in a flexible exit plan. This protects your department and medical staff in the event you’re unhappy following a strategic change in the payer’s market plans. You may not want out of the contract today, but you may some day, Hanna says.
• Consider minimum thresholds on specific issues. Set clear limits in the event the health plan wants to reduce costs by cutting your payments or hedging on covered procedures. This precaution also can work on curbing payment delays, Hanna says.
• Increase the quality of your documentation. Document thoroughly in your patient files to leave few opportunities for interpretation, Clinton advises. During periods of transition, health plan reviewers may see things differently, which can alter payments and raise disputes.
• Advocate for policies to minimize the ED’s dependence on routine procedures. Pressure from payers to curb non-urgent medical visits will increase as health plans forge strategic alliances to lower their costs and boost market share. Don’t become an easy target, Clinton says.
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