Managed care networks provide a high source of income to healthcare practices, but practices and physicians must meet strict standards in order to maintain their membership. These standards typically include:

  • Credentialing and re-credentialing of physicians,
  • Rules for admissions and referrals,
  • Clinical quality,
  • Types of care provided and treatment options, and
  • Patient satisfaction.

If a physician or practice fails to live up to the standards set by the managed care organization, they are likely to be let go, resulting in lost patients, reduced income, and—to make matters worse—deselection from additional networks.

Rise of Managed Care Deselection

Unfortunately, deselection is on the rise owing to pressures from various sources to keep costs down. For instance, employers may put pressure on preferred provider networks to reduce healthcare costs, forcing them to let go of their less efficient practitioners. In many cases, this is done without cause.

Improvements in managed care have also reduced the demand for physicians, meaning these organizations are able to operate with fewer doctors in their networks. This means healthcare providers must adhere to stricter standards in order to remain within managed care networks.

physician deselection - Managed Care DeselectionWhy Physicians Get Deselected

  • Shifting requirement 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.

Source: Physicians News Digest

Preventing Deselection

While deselection is common, it can be prevented by taking careful measures. These include:

  • Careful review of the MCO’s standards concerning credentials, referrals, etc.
  • Review of the MCO’s policy on recommending certain treatments or services
  • Explaining test results and procedures to patients clearly
  • Ensuring patients are helped promptly 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. To be properly executed, an appeal requires careful review of the provisions set forth in your contract as well as the representation of an experienced deselection appeal attorney.