Q&A: Getting HMOs to recognize all credentials

March 19, 2010

Get your questions answered on credentialing and HMOs.

Q: I am an office manager for three physicians who are all board-certified in internal medicine and infectious diseases. They spend about half their time in area hospitals consulting in infectious diseases and caring for their own hospitalized patients. They spend the other half of their time in the office seeing their own internal medicine patients as well as seeing outpatient infectious disease cases. Some insurers are requiring that these physicians be credentialed in only one specialty, saying that this is their policy to prevent self-referrals. To further complicate things, if one physician in the group is credentialed in infectious diseases and another is credentialed in internal medicine, then they cannot cover for each other even though they are in the same group, according to some insurers. These doctors want to be able to practice their subspecialty as well as have an internal medicine practice. Do these insurers have the right to limit them? Can this be negotiated?

A: This situation is common with some of the major HMOs; you rarely would see this issue with PPOs. Some of the major HMOs work this way because they have very limited databases. They can only load a physician's name into one database, either for primary care or specialty care. This ability initially served a purpose. The way HMOs are set up to flow money is capitation for primary care physicians and discounted fee-for-service dollars for specialists. They can't mix up the pots of money; otherwise, the "risk pool" and bonus money for utilization controls gets convoluted.

So if the physicians in your practice are in a secondary specialty - such as infectious diseases, rheumatology, or cardiology - that first is board-certified in internal medicine, then they have to decide whether to list themselves as primary care physicians or specialists. The plans talk about self-referral as an issue, but it really is not a utilization problem; it is a paperwork problem. If large panels of physicians are sharing HMO dollars and see referrals from a primary care physician or a specialist in the same group, then reconciliation of funds is difficult.

The answer was provided by Kim Fenton, president, California Healthcare Consulting Group, San Clemente. Send your practice management questions tomepractice@advanstar.com
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