PREFERRED PHYSICIANS ORGANIZATIONS
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.
CONTRACTING WITH HEALTH PLANS
Physicians must practice caution when entering a contract with health plans. Here are some things to keep in mind:
• 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.
22 La State Med Soc NEW PHYSICIAN’S GUIDE
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