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Starting and Building a 21st Century Private (Independent) Practice
Insurance/MCO ChallengesRichard Sethre, Psy.D., L.P..
The basics of managed care• Definition: “ a system of health care (as by an HMO or PPO) that
controls costs by placing limits on physicians' fees and by restricting the patient's choice of physicians” (Merriam Webster Dictionary)• Fundamental assumptions: • MCO’s contract with providers, and (theoretically) vet the providers to ensure
quality;• MCO’s limit the fees paid to providers;• MCO’s use oversight to (theoretically) monitor the quality of services
provided;• MCO’s promise (theoretically), in exchange for reduced fees, a steady flow of
work and ease of payment
Bruce Bobbitt, Ph.D., Optum, Sr. Vice President of Quality Improvement, MPA Susan Rydell Award recipient
• “Managed Behavioral Health Care: Current Status, Recent Trends, and the Role of Psychology”, Bruce L. Bobbitt, Clarissa C. Marques and Deborah L. Trout; Clinical Psychology: Science and Practice, Volume 5, Issue 1, pages 53–66, March 1998. Available to “rent” online for $6.00. Highly recommended.• The importance of professional psychology: A view from managed
care. Bobbitt, Bruce L. Professional Psychology: Research and Practice, Vol 37(6), Dec 2006, 590-597. Available online for purchase for $12.• “The Current Healthcare Environment: Key Information About
Measurement, Outcomes, and Assessment for Practitioners”, webinar, Buros Testing website.
Kathleen J. Papatola. PhD, L.P, Cigna Peer Reviewer
• “Managing Managed Care’s Outpatient Review Process: Insights and Recommendations From Peer Reviewers at a Health Services Company”, Papatola, Kathleen J.; Lustig, Stuart L.; Professional Psychology: Research and Practice, Vol 46(3), Jun 2015, 161-167, available for purchase online for $12• In 6 pp. they provide an excellent summary of how the MCO peer
review process works, medical necessity criteria, and how to document what a good job you are doing in order to increase your chances of being paid and avoid audit problems. Highly recommended.
Sethre’s tips for working efficiently with MCOs• Read background articles so that you understand how MCO’s
work;• Read MCO contracts before you sign them;• Read, and be knowledgeable, about MCO medical necessity
policies for the services that you provide, particularly prior authorization requirements;• Be knowledgeable about the CBT billing codes that you use;•When in doubt, contact MCO provider services staff to discuss
your questions or concerns;• Provide legible, preferable not handwritten, documentation,
and;
- to reiterate
“Read, understand and be knowledgeable about your MCO contracts!”
Tips for increasing your changes of being contracted with MCOs
• (paraphrased from the Wall Street Journal): “Entrepreneurs identify gaps in the current market, create a product designed to fill those gaps, and take actions to convince consumers that they have a need for the product.” •When applying to an MCO, you are not entitled to be
accepted- you need to be entrepreneurial and identify the needs of the MCO and sell them on how your “product”- your skills and professional resources- will help them with their unmet needs.
• Consider regional factors:• The Metro area is saturated with behavioral generalists;• Local professional programs are adding new graduates every
year;• MCO’s evaluate your application based on the zip code of your
practice site, among other factors;• If their needs are met in that area, they are likely to reject your
application due to “lack of business need”; • You will need to sell them on how they have unmet needs in your
area and would benefit from credentialing you:• Providing evening and weekend hours;• Providing specialized services, such as PTSD treatment for
veterans, bariatric services, behavioral healthcare services, group therapy, CBT-I, etc.
• Consider practicing in an underserved area, such as rural communities or metro neighborhoods with less resources;• Consider developing specialties to help underserved communities;• Be sure that your application communicates to the MCO that you
understand how MCO’s function and are not just willing to be a provider for them but are enthused about your practice and how it can help them meet their needs.• MCO’s have contracts which require that they meet the needs of their
patient population- if their needs are met, or perceived to be met, they don’t need you. If you can demonstrate to them that you can help them satisfied their contracts, you will increase your chances of being credentialed.
The problem of relocating your office• MCO contracts are “site specific” – you are contracted for a specific
practice site (per the MCO’s perceived business need in your geographical – usually zip code, but sometimes more specific) area).• If you leave the site, you are, in effect, cancelling your contract for
that site.• If you relocate within the building, that probably would not be
considered to be a site change.• If you relocate to a new building (new street address), that may or
may not be considered to be a site change, depending upon the MCO.• When in doubt, review your contract and contact the MCO provider
relations staff.
MCO’s are subject to oversight, too.
• “Public” or “government programs”: Medicare, Medicaid (MHCP),and PMAP (Prepaid Medical Assistance Program) programs run by commercial plans: subject to very strict Federal regulations (CMS- the Center for Medicare and Medicaid Services) and State Law. • “Commercial” or “Private” companies (Medica, BCBS-MN,
HP, Aetna, Value Options):• Contract• NCQA
How credentialing applications are processedThe MCO staff assess whether they have a business need:• If yes, then they accept your application for processing;• If no, they do not accept it and inform you that your application was
not processed - this is not a denial of your application but it a “non-processing” response. You have no right of appeal, but you can request reconsideration and must provide info about why they need you.
If the MCO accepts your application for processing, and it is reviewed by the credentials committee, then you have NCQA-mandated rights. If you are denied at the credentialing review stage, than you can appeal.
Questions and Discussion
•[email protected]•www.mhconcierge.com •MN MH Practice Resources interdisciplinary listserv,
