PREFERRED PHYSICIANS ORGANIZATIONS
INSURANCE CONSIDERATIONS
A Preferred Physician Organization (PPO) is a managed care organization of medical doctors, hospitals, and other health care providers who have agreed with an insurer or third-party to provide health care at reduced rates to the insurer’s or administrator’s clients.
Medical professional liability insurance coverage is for errors or omissions causing injury during the performance of a medical professional’s duties.
Louisiana Medical Malpractice Insurance Company (LAMMICO) is the LSMS-preferred provider of Medical Malpractice insurance and rated “A” by A.M. Best.
CONTRACTING WITH HEALTH PLANS
TIPS TO REDUCE THE THREAT OF A MALPRACTICE CLAIM IN YOUR OFFICE
Physicians must practice caution when entering a contract with health plans. Here are some things to keep in mind:
• Careful listening to patients can lead to a more timely and accurate diagnosis, as well as a more satisfied patient.
• Choose which third party payers with whom you are interested in contracting. You can do this by assessing the coverage of your patient population to see which 3rd parties are used most often. Usually, 50 responses or four weeks of data collection, via survey, should give you enough information to make a decision. • Research companies. Reach out to colleagues to see if they have contracts with insurance companies with whom you are interested in establishing contracts. If they do have contracts with any of these companies, request a contact name, phone, or email address. Also, ask them about their personal experience with the company. If none of your colleagues have similar practices, you can also reach out to your Medical Director. Insurance companies also have “provider lines” which you can call for information. Ask them if your practice will be considered a “medical practice” or an “ancillary practice.” They often have different employees handling these types of applications. • Contact insurance company. Try to get the name and number of a contact person and ask them to send you an application. Companies often ask for a letter from your clinic requesting to become a provider. • Get a NPI (National Provider Identifier) for practice and clinicians. A NPI is a 10-digit code identification number given to healthcare providers in the United States by the Centers for Medicare and Medicaid services (CMS). • Credential your clinicians. Register your clinicians with the Council for Affordable Quality Healthcare’s (CAQH) - Universal Provider Datasource (UDP). Keep copies of all clinical licenses, medical degrees, DEA information, overhead insurance coverage, board member’s information, hours of operations, NPIs, Tax ID Number, and SSN of managing officers. You will need these to complete the application. • The application. Keep a copy of your applications and attachments for your records. Follow up regularly with questions such as: • The status of your application. • When the board meets to approve new applications. • How long will it take to receive the fee schedule and contract (once your application is approved). • When you may begin charging the insurance company for their covered patients.
• A calendar log or suspense sheet can be created to ensure timely follow- up on receipt of test results.
• After reading incoming reports from labs and consultants, initial and date prior to filing.
• When too rushed to write complete notes, remember dictated notes are quick, legible, and tend to be more descriptive than handwritten documentation.
• Avoid any appearance of an altered record: never scratch out, erase or obliterate with “write-overs” or “white out.”
• Use a routine format to ensure complete and defensible medical records.
• Preprinted forms can be used to easily document after hours phone messages and can later be secured in the patient’s record.
• Utilize the consent form recommended by the Louisiana Medical Disclosure Panel, in addition to progress notes, to best document informed consent discussions, always remembering not to imply or guarantee treatment will be complication free.
• Remember to advocate for your patients and avoid the appearance that economic considerations override sound medical judgement.
BILLING AND REIMBURSEMENT
An important part of today’s medical practice is getting reimbursed for services. The categories of physician reimbursement relationships are listed below.
TRADITIONAL INDEMNITY INSURANCE
The Louisiana market is dominated by Blue Cross Blue Shield of Louisiana, which offers traditional indemnity insurance, PPO, and HMO plans. Indemnity plans allow you to direct your own health care and visit almost any doctor or hospital you like. The insurance company then pays a set portion of your total charges. Indemnity plans are also referred to as “fee-for-service” plans.
24 La State Med Soc NEW PHYSICIAN’S GUIDE
La State Med Soc NEW PHYSICIAN’S GUIDE 25
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