What to Consider When Joining Managed Care Networks

Though it's a given that most D.C.s will want to belong to Medicare and Blue Cross/Blue Shield, you may also wish to consider joining other networks. Many major health insurance plans contract with chiropractic, so there may be significant benefits in joining the right network. Keep in mind, however, that some do not routinely accept new doctors.

Posted in Patient Experience on Friday, January 15, 2016

For a list of the managed care companies in your area, contact your state insurance department (refer to www.usa.gov for information on your state insurance department). Or your state chiropractic association can provide a listing.

But, before you affiliate, there are several things to consider about each organization. You might want to call or review their website for information. And, consider the following about each organization:

What kind of network is it?

Each type of managed care network operates differently, so it's important to know what type of organization you would be joining.

• Health Maintenance Organization (HMO) - offers policies, collects premiums and bears financial risk. HMOs require care be delivered by HMO-approved providers.
• Preferred Provider Organization (PPO) - if a patient receives care from a PPO-affiliated doctor, a higher portion of the cost of care is paid for than if they see a doctor who is not affiliated with the PPO.
• Independent Practice Association (IPA) - these are health care professionals (often including chiropractors) who maintain their own separate practices while forming an MCO to contract with purchasers to provide care at established rates.
• Physician Hospital Organization (PHO) - these are legal entities formed and owned by one or more hospitals and physician groups to obtain payer contracts and to further mutual interests.

Does the network meet licensure and accreditation criteria?

• Does it comply with qualification requirements?
• Is it licensed by the appropriate agency in your state, e.g., the health or insurance department?

What marketing and service area does the network serve?

• Does the plan provide all enrollees with comprehensive information about chiropractic benefits?
• What are the procedures for selecting a chiropractic provider?
• How does it market itself to subscribers?
• Will the network provide you with copies of its marketing materials (brochures, posters, etc.)?
• How many chiropractors does the network contract with?
• Who are the primary care physicians within your area and where are their offices located?

What does the plan require and allow?

• Does the contract provide for cancellation if you are not satisfied with the arrangements?
• Does the plan have a “hold harmless” arrangement with providers? (This type of clause specifies that the network and the doctor will not hold each other liable for malpractice or corporate wrongdoing if the other party is found liable.)