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Navigating Managed Care Contracts and Provider Participation

By Maria Todd, PhD, MHA
Preview of 2024 AMWA Annual Meeting Plenary Presentation

As a consulting doctor of health administration with 47 years of experience working side by side with physicians in the USA and 120+ countries, one issue that always comes up is the resentment about managed care coverage for services that the physician wants to perform or prescribe for patients but feel they “can’t”. The narrative and mindset need to change to help you to adjust your perspective.

It may surprise you that managed care is a system of health care financing that is established throughout the world; not just in the United States.

As women physicians, you’re undoubtedly aware of the complex web of healthcare systems and insurance plans that dictate patient care in today’s medical landscape. Managed care contracts and provider participation are critical components of this intricate system, and understanding them at a basic level is essential for delivering quality patient care while managing the constraints of insurance coverage.

Covered Services vs. Medical Necessity

One of the fundamental distinctions you need to grasp when dealing with managed care contracts is the difference between “covered services” and “medical necessity.” These terms may seem straightforward, but they can have a significant impact on patient care.

Covered Services: Covered services are those treatments, procedures, and medications that a patient’s insurance plan will pay for. These services are typically outlined in the managed care contract, and they can vary widely from one plan to another. As a physician, you must be familiar with the specifics of your patients’ insurance plans to ensure that the services you provide are covered.

Medical Necessity: Medical necessity refers to the clinical judgment that a particular treatment or service is necessary to diagnose, treat, or prevent a medical condition. It’s important to note that what may be medically necessary isn’t always a covered service under the patient’s insurance plan. As a physician, your primary duty is to provide care that aligns with the patient’s clinical needs, regardless of whether it’s covered by insurance.

Abdication of Responsibility

One crucial point that all physicians, including those in training, must understand is that you should never abdicate your responsibility for the duty of care simply because “managed care won’t pay for it.” While navigating the complexities of insurance coverage can be challenging, your foremost duty is to your patients’ well-being.

Here are some practical steps to ensure you uphold your duty of care:

  1. Thorough Documentation: Document the medical necessity of your decisions and treatments. This documentation is essential when justifying your actions to insurance companies or regulatory bodies.
  2. Communication: Open and honest communication with your patients is key. Discuss treatment options, potential out-of-pocket costs, and any alternative therapies that may be covered by insurance that they may wish to try first. Be transparent about what you believe insurance will cover and what they patient may have to pay for and see if there is a way to find them a medical loan program to help with affordability.
  3. Prior Authorization: In some cases, it may be necessary to seek prior authorization from the insurance provider for certain treatments or procedures. Familiarize yourself with the process and ensure timely submissions.
  4. Appeals Process: If an insurance claim is denied, don’t give up. Many insurance plans have an appeals process that allows you to challenge denials based on medical necessity. Advocate for your patients when necessary. Be very observant about time limits for appeals because if you exceed the time limit, your appeal can be foreclosed.
  5. Resource Utilization: Be mindful of resource utilization. Utilize cost-effective and evidence-based practices whenever possible, without compromising patient care.

One way that I have successfully tackled the medical necessity hurdle was to go into Noridian and pull down the medical necessity criteria for a total knee replacement and total hip replacement and carpal tunnel release for an orthopaedic surgeon. I turned the criteria into a checklist.

When the surgery scheduler applies for prior authorization through the insurance plan portals, all the questions are answered on the sheet from an interview with the patient. This is a ready reference tool to answer the questions on screen. Then, it asks for an upload of information. The scheduler uploads the medical necessity sheet along with x-ray report for joints and the EMG/NCV for the carpal tunnel diagnostic study and even if the request is pending review, it clears review in a matter of a day or so instead of the usual two weeks. This is because everything they need is right in front of them in the same order they review the case, and is easily passed and approved.

Join us at #AMWA2024, March 22-24 (virtually) to learn more from Dr. Todd, one of several compelling sessions aimed at better preparing women in medicine to: Secure Your Future in the Changing Landscape of Medicine.

Jodi Godfrey

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