Tips for Practicing in a Managed Care Environment

1. Before signing any MCO contract, seek appropriate consultation to ensure that you understand what you are signing (i.e., your personal attorney, the APA Managed Care Helpline, or the APA Legal Consultation Plan).

2. Before signing any MCO contract, seek appropriate consultation to be sure the contract does not violate your professional liability insurance policy (i.e., your personal attorney, the APA Managed Care Helpline, or the APA Legal Consultation Plan).

3. Carefully review any indemnification clauses, "hold harmless" clauses, "joint and several liability" clauses, and "incorporated by reference" clauses. Be aware of what you are contracting for and know whether or not you have insurance coverage.

4. Assess capitation arrangements carefully.

5. Do not gloss over any words or definitions. Do not assume they are self-evident.

6. Are the physicians’ responsibilities clear and reasonable?

7. Obtain copies of all rules, regulations, and requirements, etc. prior to signing a contract.

8. Get verbal promises in writing.

9. Know who owns the plan, and who the founders, operators, and managers are.

10. Ask your colleagues about their experiences with a particular MCO.

11. Does the plan have an accessible, respected network of physicians and hospitals? Can patients obtain comprehensive care from that network?

12. Know how ancillary services are obtained.

13. Know about the MCO’s policy regarding release of records and information.

14. Remember, an MCO contract cannot change your professional obligation to your patients. You remain responsible for them.

15. Before signing any MCO contract, inquire as to whether there are limitations on what you may discuss with your patients regarding treatment options, utilization review, etc.

16. At the outset of treatment, discuss with patients the mechanics of utilization review, any potential payment limitations, any incentives to the physician to limit care, and the scope of access which reviewers and other insurance representatives have to patients’ records. Be aware of any limitations your contract might place on such discussions.

17. Document patient care thoroughly. Likewise, document recommendations and determinations made by reviewers and your responses to such determinations.

18. Appeal any denial of recommended treatment. If an appeal is denied, appeal again.

19. Accurately state the patient’s condition when filing an appeal. Do not exaggerate.

20. Do not "abandon" a patient when further care will not be reimbursed. Examine all available options. Appropriate termination is permissible.

21. Be professional and courteous to MCO staff during referral, authorization, billing, eligibility, and other processes. Document each interaction, including the staff member’s name.

22. Maintain accurate and updated malpractice insurance, credentials, and recredentialling materials.

23. Obtain updated versions of the CPT codes as required and review them at least annually.

24. Always notify your insurance company of any changes in your practice that could effect your coverage (i.e., location changes, personnel changes, employee behavior, independent contractors, consultants, and services).

The information contained in the web site does not constitute legal advice. If you are a Program Participant please call (800) 245-3333 for further risk management advice or risk management advice concerning a specific situation. For legal advice contact your personal attorney.