MCO Closed Provider Panels: Can They Be Opened?

"I continue to believe-especially as we have seen it work-that patient activism is the best way to pry open these closed panels," says Cathie Griffith, president, PrimeCare O&P Network, Ellendale, Tennessee. "Call it squeaky wheel syndrome, if you like. The challenge is to get the patients to act, once they have had to be turned away from a provider." For someone who is ill or has transportation problems, it is just simpler to follow the course of least resistance and go to the provider who is on contract, even if the patient is not as comfortable with that provider, Griffith notes, adding that many patients simply don't have the energy or strength to do battle with their insurance provider. Griffith describes a program PrimeCare has recently implemented, in which providers are equipped with patient activism forms that allow them to provide patients with the specific contact information and ammunition they need to effectively register their provider preferences and specific complaints with their insurance company. In addition, copies of these signed forms allow O&P providers to track and document cases of patients expressing a preference that their care be shifted to the provider's facility. Results are still out on this new program, Griffith reports, but she stresses that the program was implemented in response to anecdotal results due to patient activism reported by PrimeCare members. Create a Competitive Advantage Closed panels are another fact of life that can easily last forever, observes Alison Cherney, president, Cherney & Associates, Brentwood, Tennessee. Calling the MCO and asking to be put on a provider panel is not the most efficient approach to the problem: "You're talking to a secretary who has little or no interest in letting you on their provider panel," Cherney says. "You've either got to go to the back door, or you have to create a competitive advantage for yourself. What are you going to offer that other O&P providers can't?" Such advantages could include a larger geographic area, a more interesting disease management program, and paying emergency room visits. Most providers admit that they have no such unique advantage to offer, she adds. Quality of care is only an advantage when it is provable, Cherney emphasizes. "If patients come to your facility with a legitimate complaint, saying that they have received an unsatisfactory level of care from your competitor who is on the PPO panel, then get their records and take these cases to the medical director of the PPO and point it out to them." But in the vast majority of cases, she believes, most O&P providers offer a reasonable level of care, making superior quality-of-care comparisons difficult or impossible to prove. Do State Laws Help? "Unfortunately, in most cases, there is no statute of limitations on how long the major MCOs can keep their panels closed to new providers, and most states have no applicable laws," says Keith Senn, chief operations officer, Center for Orthotic & Prosthetic Care, Louisville, Kentucky. Some states reportedly have an "any willing provider law" which stipulates that as long as providers meet the insurance company's written standards-for American Board for Certification in Orthotics and Prosthetics (ABC) certification, liability insurance coverage, etc.-the insurer must accept them on their provider panel if the provider wants a contract. And in North Carolina, recent legislation outlawing "steering" of auto insurance clients to one or two "favored" body shops has now perhaps opened the doors for service providers in other insured areas to demand a similar opening of provider panels. Be sure to check legislation in your own state regarding the status of these relevant issues. Talk to the Right People Most MCOs, like Anthem and Blue Cross/Blue Shield, won't go with just one provider in an area, Senn observes. "They'll want to have a choice of providers on their list. If the panel is closed, however, there are still avenues open to you. Talk to the right people, such as the network development manager and the medical director. The network development manager has the power to let new providers in at any time, under any circumstances, if he decides he wants to," he says. "It can also help to talk to the medical director regarding your desire to be included as a provider; and it does help to prime the patients to contact their insurance company with their request that you be a provider," Senn continues. Senn advises O&P providers to emphasize important and valid reasons for inclusion on the panel, such as convenient locations, certification, their record of service in caring for specific patients who are now, possibly, being denied their provider's care due to changes in their insurance. "Be persistent," Senn urges. Work with Strategic Partners Cherney disagrees. "For the most part, I don't think consumers care. I think you have to work with the hospitals and/or the large doctor groups in order to make a difference. You need to have what I call 'strategic partners.' In other words, if I am Humana and I'm coming into Phoenix, and there's only one orthopedic group or one large multi-specialty group that my patients like, I've got to play ball with them. I need to be working with their contracting and provider relations people to make sure the contract gets changed; then I go in and say I want the same contract that the medical group has." But O&P providers tend to be rugged individualists, she jokes, "They're reluctant to ally themselves with a hospital or major physicians' group." As independents, most don't have a big budget to spend on consumer marketing, she noted. The fastest, cheapest way to get a contract changed is to work with a large medical group or hospital-and get friendly with them, Cherney points out, adding, "Tell them, 'I don't like this. Can you get this contract changed? And then we'll follow suit...'" Making powerful friends is what it's ALL about, says Cherney. "If your O&P business is going after PPO and TPA business, you should recognize that you're a very small percentage of the dollar-less than a quarter of a percentage point." Hospitals and large primary care physician groups have the most clout, Cherney says, adding, "So if anybody's going to push back on a contract, they'll have the best success." Cherney noted that this effort has been successful in later-stage markets such as California and Arizona, where doctors are simply refusing to sign such contracts. "It's when large blocks of dollars and people get together and push back on the payers and say 'We're just not going to take this anymore,' that you see contracts being changed," Cherney says. "Do I think an O&P provider can make that happen on his own, without powerful friends to assist? Probably not." Judith Otto is a freelance writer based in Holly Springs, Mississippi.

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