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As independent practice psychologists, many of us remain on managed care organization (MCO) provider panels. One of the privileges of such is providers are required to be recredentialed on a regular basis. Often this a time consuming process, and can be a real "time robber."
Recently I received such a letter informing me that in order for the MCO to maintain its "high standards," it was necessary for me to complete a lengthy packet of information in order for me to remain on the panel. The materials must be completed and returned to the MCO (let's call it the XYZ MCO Company) within 10 days or else I would be disenrolled from the provider network.
After 21 years of practice, I no longer believe that it is imperative for me to be on every MCO that sends me an application or a recredentialing packet. In the last few years I have resigned from panels and have not joined any new panels. Further, in the last few months, I decided that the MCOs were right about at least one aspect of their endeavors: companies, like providers, need to be reviewed for their performance in a number of areas. Just as MCOs are concerned about providers who fail to file claims in a timely fashion, are unable to see "crisis clients" promptly, etc., I believe MCOs have a responsibility to their providers to comply with a set of standards. With this in mind, I started informally looking at factors such as:
- reimbursement rate,
- number of individuals presenting with that particular managed care coverage,
- number of referrals received,
- courteousness and responsiveness of provider relations representatives, and
- timeliness of reimbursement.
This is only a partial list of criteria that I might use in my evaluation process of MCOs.
The good news is some companies have performed in an excellent fashion, and frankly it is a pleasure to work with them. Unfortunately, this review has also resulted in some outliers, and as a result, I have decided not to pursue the recredentialing process, as evidenced by the letter below to XYZ MCO.
The purpose of sharing this process and letter with members of Division 42 is to encourage a process by which we develop a list of standards that we could use, perhaps even in a formal way, to evaluate the performance of those companies with which we maintain a relationship. I agree that managed care companies should be concerned about the performance of their providers, and "bad apples" can be eliminated. Likewise, not all MCOs are created equally, and I think it is important that we review and weed out "bad apples."
What follows is the letter to XYZ MCO.
February 6, 2001
Dear
I am in receipt of the recredentialing packet from XYZ MCO with instructions to complete within 10 days.
Just as it is critical that managed care companies review credentials and performance of their providers, likewise I believe that it is imperative that providers review the performance of managed care companies with whom they maintain contracts. To this end, I have initiated a review process that considers the following criteria: reimbursement rate, number of individuals presenting with that particular managed care coverage, number of referrals received, courteousness and responsiveness of provider relations representatives, and timeliness of reimbursement. Below are the results of my review of XYZ MCO.
Reimbursement Rate: Your company is generally on par with most major companies with whom I work.
Number of Individuals with Your Coverage Seen in the last 3 Years: 1
Number of Referrals: 0
Courteousness/Responsiveness: Poor. Calls to provider relations have required multiple transfers to other representatives, representatives (with only one exceptions) have demonstrated difficulty in resolving problems, and in one case, the representative was quite rude.
Timeliness of Reimbursement: Extremely Poor. The average time required for reimbursement on claims submitted the same day of service has exceeded 90 days, and in some cases, a time period of one year was required before payment was received. Multiple telephone calls, resubmissions of claims, et c. were required, and to date, I have still not received reimbursement for a claim submitted in November, 2000.
While I strongly suspect that the reactions of one provider are of little concern to your organization, I nonetheless wanted to offer this feedback. I find it interesting that your mailing requires prompt response, and the contract requires that clients be seen "immediately" in some cases and in no less than 7 days for routine referrals (which I have never received). Yet, representatives of your company can take days to return telephone calls, or in some cases never return the call, and reimbursement can take up to one year. These behaviors seem interesting when taken in the context of your letter that stated: "Thank you for taking the time to assist XYZ MCO in our commitment to a high quality provider network." A favorite saying of mine is, "Listen to the words, and trust the behavior," and it seems that the behavior I have experienced with your company is perhaps not as consistent with "high quality" as I might hope. Granted, this may be the exception and not the rule, but my evaluation of the performance of XYZ MCO over the last three years is the only data with which I am confronted.
Hence, after careful review of the performance of your company, I am returning the credentialing materials and have not completed these materials. In keeping with likely requirements of the contract, this letter can serve as notification that I no longer desire to be a provider with XYZ MCO.
If I can provide additional information, please feel free to contact me.
Sincerely,
Edgar J. Nottingham, IV, Ph.D.
Clinical Psychologist
Licensed Marital & Family Therapist
Fellow, Academy of Clinical Psychology & American Academy of Behavioral Psychology
Diplomate in Behavioral & Clinical Psychology
American Board of Professional Psychology (ABPP)
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