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MCOs: Keeping Track of the Players
By Judith Otto How often do the MCOs/HMOs metamorphose? Is it true that
they are buying each other out, changing names, and absorbing other
MCOs at a faster rate than ever? How many insurance companies is it
possible to hide under one umbrella? To how many other companies
might you be connected by a contract without ever being aware of
it? Is this an attempt to be intentionally obscure?
"This has been going on for ten years," says Alison Cherney,
president, Cherney & Associates, Brentwood, Tennessee, "but it
may be happening more slowly than it was five years ago. There is
still consolidation of managed care, but I would say that the pace
has slowed down over the past couple of years."
Keith Senn, chief operations officer, Center for Orthotic and
Prosthetic Care, Louisville, Kentucky, believes that MCOs/HMOs are
evolving at largely the same rate they always have. "The smaller
ones continue to go out of business or are bought by bigger ones as
they fail to compete. Even established companies like Humana can
decide to pull up stakes and leave a state if they decide it is an
unprofitable market for them."
It pays to keep a close eye on everything going on out there,
Senn advises. For example, Humana recently quit selling its
Medicare replacement plan, turning it over to Anthem. "Stay sharp,
keep up," is his earnest advice. "An existing patient may now be
covered by Anthem—so we'll have to preauthorize treatment the
next time he comes in. And we won't know this until the patient
presents his card with the new information."
This is why it's important to get preauthorization on all work,
he points out—or at least, to verify benefits each time. By
looking at the patient's current card, you'll at least know who the
patient is currently covered by and what your reimbursement status
is likely to be. If you're not sure, call the number on the card
and ask, "Are we participating with your plan? Here's our Tax ID
number—please check."
When a company is bought out, it should be ethically bound to
notify its providers, explains Cathie Griffith, president,
PrimeCare O&P Network, Ellendale, Tennessee. "However, ethics
evidently can be fluid in this business, and there is no legal
remedy that I am aware of if MCOs don't notify providers. This is
very much related to the silent networking issue, in my
opinion."
Personnel Changes
If it's hard to keep track of the MCOs/TPOs without a scorecard,
how much harder is it when their employees change frequently, too?
Is this constant migration of contact personnel a clever stratagem,
or is it the nature of the business that employees play musical
chairs so often?
"They always change," says Cherney. "That's just an industry
joke. You have to stay on top of them. Every week in our management
meetings, we talk about who's changing and what we need to do
strategically to stay with them."
"Personnel changes are really a headache for everyone," Senn
agrees. "You just get comfortable with a phone contact at an
insurance company, then they're gone and you have to go through the
entire drill again—introducing yourself, explaining your
situation as a provider, and developing a good cooperative working
relationship. This constant shifting around is really just the
nature of the business, however."
Keeping up with the MCO scorecard is indeed challenging, but
worth the effort in helping you gain contracts. Judith Otto is a freelance writer based in Holly Springs, Mississippi. 
Table Of Contents - October 2002
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