<img style="float: right;" src="https://opedge.com/Content/OldArticles/images/2002-10_07/Otto,-J-PE.jpg" hspace="4" vspace="4" /> A "Nightmare on Elm Street" aptly sums up how many O&P providers feel about managed care contracting. Previous articles explored "rate shopping" and strategies for opening closed provider panels. Here, some experts from the front lines describe more pitfalls and how to survive them. Any other tricky little surprises you're encountering on the contracting front lately? Any solutions or advice? Sheila Press, Esq., MBA, president, Health Care Compliance Solutions, Scottsdale, Arizona, notes that contracting involves certain legal terms like "usual and customary," which must be carefully defined. "In my own contracts, I attach an 'Addendum A,' identified as a 'Scope of Work,' so it is clear exactly what services clients are receiving and paying for," she explains. If contractual obligations are not met, the situation can often be resolved without dissolving the contract, she adds. Citing an example, she says, "In one case where terms of payment were defined as 45 days and payment had not been received after 120 days, I went to the chief financial officer of the client company-sometimes the medical director is also an appropriate source-and advised him that the terms of the contract were not being met, pointing out that it was not to the advantage of either of us to end the contract. This has been a productive and successful approach in gaining resolution." Cathie Griffith, president of PrimeCare O&P Network, Ellendale, Tennessee, gives this advice: "Don't sign anything unless you know exactly what you're signing." She also offers a word of caution when examining contracts: "Look for language that describes the Third Party Organization's (TPO's) procedures with regard to how it 're-prices.' The 'good guys' will use the first contract as the primary contract and price from that; i.e., if a provider has an existing contract that reimburses at a higher rate than a subsequent contract, the first contract takes precedence. "On the other hand, if they have an existing contract that reimburses lower than one that is negotiated by PrimeCare or another entity on their behalf, they must provide a letter stating that they prefer to be reimbursed at the later contract's rate," she continues. "If this language is not in the contract, then the TPO is free to 'rate shop' and see which contract reimburses lower and use that price." "Try to participate in every contract you can afford to," advises Keith Senn, chief operations officer, Center for Orthotic and Prosthetic Care, Louisville, Kentucky. "Check carefully each time patients come in-even if you've known them for years and think you know their coverage. Verify and obtain preauthorizaton in all cases to make sure." Checking membership cards is the provider's responsibility, Senn says, adding, "This must not be overlooked, or you'll definitely suffer for it." "Even so," he admits, "this process only allows you to flag problems-it doesn't solve them. But it at least alerts you before you get into costly trouble by fitting an expensive prosthesis to someone whose insurance is not likely to pay you. And you'll be in a position to make an informed decision before it's too late." "Insurance companies are in the business to protect themselves," points out Alison Cherney, president of Cherney & Associates, Brentwood, Tennessee. Contracts are usually very one-sided and designed only to protect the Preferred Provider Organization (PPO), she notes. Of providers who complain that they aren't able to identify patients-don't know who's holding their contract, who's covered by their contract, and can't keep up when patients don't come in with a sticker on their card-Cherney says, "They just need to pay closer attention and stay on top of the administrative part of their contract." <h2>Be Proactive</h2> "It's about being proactive with your payers," she insists. Cherney is the part-time chief marketing officer for a radiation-oncology group which holds 25 managed-care contracts in Phoenix, Arizona, which is considered one of the most advanced managed care areas in the US. "Two of the contracts represent 60 percent of our business. And I can tell you that we know every detail of every contract; and we know what's going on with every patient who walks through our door We have a dedicated group that handles this," she continues. "When you get 95 percent of your business from managed care contracts, you pay attention." Cherney suspects that most of the complaints about keeping up with managed care contracts are coming from providers in rural or less-developed markets: "They're just going through the same product life cycle in managed care that people in Los Angeles went through. They probably need to talk to their counterparts in these more advanced markets and learn what techniques have worked well for them." "If you're going to play on the playground," Cherney concludes, "you've got to play with the other kids, and you've got to pay attention to the rules of the game." <h2>What's Next?</h2> Inevitably, more issues loom on the managed care horizon. Some can be anticipated: For example, the Medicare competitive bidding demonstration programs in Florida and Texas could be expanded if legislation allows. This promises to be a nightmare if ever there was one. No doubt there are other, unanticipated surprises in store as well. If, in the final analysis, we seem to be left with more questions than answers, it's because nobody who can explain and suggest solutions-i.e., MCOs-is talking. And as Cherney points out, why should they? The MCO contracting arena IS still a waking nightmare for most small O&P businessmen-filled with perils, pitfalls, and unpleasant surprises for the unwary. If you dare to venture within, feel free to mix your metaphors and treat it as a jungle: be sure to take a very sharp machete. <i>Judith Otto is a freelance writer based in Holly Springs, Mississippi.</i>
