Why Should You Sign That Mangled Care Contract?
No – the title does not have a typo in it – Don Self and Associates originated the term “Mangled Care” because it more accurately reflects the system than does the term “managed care”. Mangled Care can be an excellent system to be a part of, promote or profit from, if you’re an insurance carrier. In our opinion, if you are a physician or a patient, mangled care can be not only a nightmare, but it can seriously impede the care a patient receives, disrupt the physician-patient relationship or create a financial havoc in your business. Conversely, there are some physicians and practices that have learned to not only survive mangled care, but to profit from it at the same time. Unfortunately, this is a minority of medical practices and the vast majority we have reviewed do not even realize they may have not only relinquished control of their practices, but at the same time are losing money by seeing mangled care patients. Every professional (physician, attorney, accountant, office manager, etc) in the world should have an idea of what their time is worth. Unfortunately, when many physicians examine the amount of money they make in an hour seeing mangled care patients and then compare that to how much they make by seeing non-mangled care during the same hour – the difference is startling.
“But Don, If we don’t see managed care patients, we won’t be seeing patients!” In some markets that is true, but there are far more geographical areas of this country that it isn’t. Unfortunately, the AMA (in our opinion) has not helped the physicians in this area nearly as much as they have helped the insurance carriers, so we cannot count on them to help. It has to be you that takes a proactive stance to regain control of your practice.
THINK BEFORE YOU SIGN
“OK – how can I make sure I’m making money and not losing money by seeing managed care patients?” The most effective way to make a difference in your own practice is to stop signing every mangled care contract that comes across your desk. I am constantly amazed at some of the garbage that physicians and practice administrators sign – because they don’t realize they can negotiate with the carriers. You wouldn’t go to a new car lot and pay the sticker price for a car, yet you sign these contracts with provisions and clauses in them that is tantamount to paying list price PLUS $5000 for a new car. It’s like a woman having an expensive dinner date with a wealthy gentleman that stuck her with the bill and then asks him to take her out again. It’s time to wake up to reality. Here are a few tips that you can accept if you’re tired of being led around on a leash by mangled care companies:
1) Have a health care attorney review each and every contract before you sign it (No – not the same attorney that handled your divorce, bankruptcy or home purchase). Attorneys specialize the way physicians do and you wouldn’t go to a Podiatrist to have a vasectomy would you?
2) Change the contract mailed to you. We recommend you not make any changes to the first page or the last page that has a place for you to sign if possible. In between those pages, look for the following and change them to your specifications, initial each change and make sure you copy the entire document before signing the last page and mailing it back to them:
a. Claims filing deadline: Some contracts have you limited to 30 days. We recommend you change this to 180 days. Be sure to initial your change.
b. Patient divorce policy: Some policies prohibit you from divorcing patients on their plan for any reason, including failure to show for appointments, failure to pay co-pays, failure to follow regimen, or even providing you with urinalysis samples IN THE RECEPTION AREA. We recommend you completely mark through that clause and initial it.
c. Contract termination policy: We’ve seen some that stated the provider may terminate the policy by giving 30 written notice and the termination becomes effective in November of the subsequent year the termination notice is received. We recommend you give them no more than a 30 day termination notice.
d. Prohibition against charging members for non-covered service. Believe it or not, we’ve seen several contracts that prohibited you from billing the patient for services not covered by the plan. Eliminate this clause.
e. Plan Payment Amount Revisions: Most contacts give the plan the right to change the approved, allowed, or payment amounts at the discretion of the plan with no recourse by the provider. That would be like you and I sitting down to play chess and I had the right to have my pawns exercise the same moves as my queen. What do you think of the fairness of that game? Eliminate it or add the stipulation that advance written notice must be acknowledged by the provider at least 60 days before such revisions took place. That gives you time to bail out.
f. Make sure the plan stipulates that current CPT codes and modifiers will be recognized and honored by the plan. As an example, many plans do not accept the modifier 25 which allows you to bill for E&M services on the same day as a procedure when the visit is separately identifiable. Cover yourself.
Before you sign up on the plan, send a fax to the plan listing 10 of the most common procedure codes (visits, procedures and diagnostic tests) that you do most often and demand to know their payment amounts. Compare this to your usual income. If you follow these steps – you have a better than average chance of coming out ahead. If you do not, then it’s your own fault you’re losing money – not the mangled care company’s.
Don Self, CSS, BFMA, is Chairman and CEO of his own healthcare receivables consulting group, Don Self & Associates, Inc., Whitehouse, Texas. His company specializes in providing consulting services to healthcare professionals covering such topics as, Claims Coding, Physician Fees, Collections, Medicare & Medicaid Changes, Increasing Reimbursement & Medical Reimbursement Issues. Visit their website at http://www.donself.com.
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