Insurance Contract Acquisition

[Injection]

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Hello All-

I am a pain fellow preparing to start my own practice over the next few months. I am entering an area which is notoriously quite competitive. Ive heard that there canbe difficulty contracting with HMOs in the area.

Is this valid? It seems to me that they would only benefit from our business, so contracting would be easy, although negotiations may be minimal.

ANY input here would be appreciated! Thanks!

 

[Aether2000]

There was a limited focus Supreme Court decision a few years ago that would compel HMOs to make their contracts available to all physicians who would apply on equal footing. But this is not enforced, and HMOs generally select physicians who will do next to nothing for their patients. Physicians who recommend expensive procedures may find themselves without a contract the following year. Since HMOs effectively have a built in incentive to not treat (kickbacks to physicians who do not cost the company much money and kickbacks to screening nurses who frequently do not approve procedures), it is usually in the best interest of pain physician specialists to avoid HMOs whenever possible. But if market penetration of these entities is high, one may have to sleep with the enemy for awhile until their insured patients with private or corporate health insurance become a significant part of their practice. But the face of American medicine is rapidly changing and within the next few years, HSAs and cafeteria plans will make patients more selective about expensive procedures as patients bear more and more of their cost out of pocket. The future is not HMOs. They are expensive elephants that cannot adjust quickly to the rapidly evolving marketplace.

 

[stim4u]

Algos:

Are you accepting Independence Blue Cross (ie. Anthem, keystone), and if so, are you taking the PPO plans or all HMO plans. What percentage of your payer mix is HMO/PPO, private insurance, medicare, and WC. As a new incoming solo physician to an area would you recommend accepting as many carriers and insurance plans as possible and then becoming more selective as the volume increases?

Thanks.

 

[Aether2000]

Our current payor class mix is:
40% private insurance with one small PPO
27% Anthem PPO and traditional
26% Medicare
3% Medicaid
2% Self Pay
2% WC
0% HMO

If I were coming into a new area, I would do exactly as you propose: enroll in everything at first.

 

[Tenesma]

HMOs suck... they will tell you that their board is closed... which is a lie... legally they have to open the board at least twice a year, and they publish that little info in the back of some crappy local newspaper, so nobody ever finds out. Even once you get on the HMO board of approved docs, they can kick you out just as quickly....

I had a friend who was getting mega business from Texas Instrument employees and then as soon as TI made a change in their insurance to an HMO carrier, he literally lost almost all those patients - the patients unfortunately have little say in all of this. Do you know who has a say? Texas Instruments and they are interested in the lowest rates possible and are more than glad to stay put with the cheaper HMO...

 

[Disciple]

HMOs suck... they will tell you that their board is closed... which is a lie... legally they have to open the board at least twice a year

Is there a specific law that covers this?


Any Willing Provider Laws


Has anyone here ever invoked these to force their way onto an HMO panel?

 

[Doctodd]

You can do what the orthos do and dont get on any/or many contracts....you can see patients in the hospital and use the hospital's authorization. The HMO's have to pay you....but most pain docs dont want to leave the office cuz it isnt financially worth it. If you do procedures in the hospital for these insurances you dont have contracts for, the facility fee being about 5 times what the professional fee is, it might change their mind. When they see what it is costing them, it may be in their best interests to get you on a contract.

 

[Disciple]

Thanks,

I remember you posting something similar previously on another thread (about the inpt consults that is).

On the other hand, the hospital I'm at seems to be on the lower end of the curve as far as business savvy goes, and I believe it's the established physicians on the medical staff who are blocking entry for new doctors onto the HMOs.

 

[Doctodd]

ive never heard of that one....are they on the board for the HMO's? I dont think they would have any say unless they are contracted with the insurance companies and that is a stipulation in their contracts.....they may also have capitation agreements where they get paid an annual amount.

 

[Disciple]

ive never heard of that one....are they on the board for the HMO's?

No, but they have influence within an IPA (a big one) which is affiliated with the hospital.

I have actually offered to provide a service that many of the hospitalists are requesting (and no one is providing, i.e. inpt pain consultation service), and they are still blocking me.

 

[Doctodd]

if you are anesthesiology then i cant offer any solutions....if you are PMR i would try to get on staff under that guise.

 

[Disciple]

Ironically, in this case it's the Physiatrists who are doing this.