What Is Managed Care Deselection?
Managed care networks (MCNs) provide a high source of income to health care practices. If a physician is let go from an MCN, it can lead to lost patients, reduced income, and – to make matters worse – deselection from additional networks.
At Kennedy Attorneys & Counselors at Law, our attorneys have worked with medical practices from Dallas, across Texas and nationwide in combating deselection to ensure proper reimbursement. We take a proactive approach that ensures all credentials are up to date and all providers are in total compliance.
Rise Of Managed Care Deselection
Deselection is on the rise owing to pressures from various sources to keep costs down. For instance, employers may pressure preferred provider networks to reduce health care costs, forcing them to let go of their less efficient practitioners. In many cases, this is done without cause.
Improvements in managed care organizations (MCOs) have also reduced the demand for physicians, meaning these organizations can operate with fewer doctors in their networks. This means health care providers must adhere to stricter standards to remain within managed care networks. There are several reasons MCNs deselect physicians, including:
- Shifting requirements from board eligibility to board certification
- Specific specialty needs, based on reduced utilization
- Physician performance factors, utilization and access
- Patient satisfaction
- Prevention and patient education programs
But, while deselection is common, you can prevent it by taking careful measures. These include:
- Detailed review of the MCO’s standards concerning credentials, referrals, etc.
- Review of the MCO’s policy on recommending specific treatments or services
- Explaining test results and procedures to patients clearly
- Ensuring patients receive prompt help without excessive wait times
- Responding promptly and efficiently to emergencies
- Monitoring costs data, including those from lengths of hospital stays, numbers of X-rays, etc.
- Presenting concerns in a professional manner and with the support of colleagues when possible
- Striving to cooperate with plan administrators
By carefully reviewing documents, treating patients, monitoring data, and working with your MCO’s administrators, you minimize the odds they will try to let you go.
Responding To Managed Care Deselection
In the event you face managed care network deselection, you may have the option to appeal the decision. Proper execution of an appeal requires careful review of the provisions outlined in your contract, as well as the representation of an experienced deselection appeal attorney.