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Eleven years ago, Medical Network
One retained the accounting firm of Monast, Hess and Imber to
perform all duties associated with financial record-keeping.
Ms. Jackie Hess, CPA is a principal
of the accounting firm and reviews all documents obtained from
the managed care organizations for any discrepancies. Ms. Hess
and assistants process capitation payments, generate the capitation
checks and monthly Physician Income Statements.
The CPAs also perform the bank reconciliation
at the end of the month completing monthly financial statements
for the corporation’s treasurer.
Currently, Ms. Hess is reviewing
the proposal submitted by Medical Network One’s Board of Directors
concerning the new risk-sharing Pharmacy Contract. The proposal
outlines the manner in which primary care physicians would be
held accountable in the event of a financial shortfall. The Pharmacy
Withhold was unanimously approved by the Board of Directors at
its’ quarterly meeting.
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The manner in which
funds would be distributed to primary care physicians was discussed
at an organizational meeting in 1981. There was much discussion
about capitation in the managed care arena but no one provided
a workable plan. Medical claims started coming in since the doctors
that established Medical Network One had already signed a risk-sharing
multi-specialty agreement with Blue Care Network and the primary
care physicians were generating referrals to local non-contracted
physicians. Claims being reviewed for payment were frequently
unbundled and the manner in which to distribute funds had reached
an impasse.
The concept was there
all along. A fixed dollar amount would be taken off the top for
administration and then the remaining monies would be divided
into two equal amounts. One amount would be sent monthly to the
primary care physician. The other amount would be kept in a referral
fund. Each primary care physician would receive a monthly statement
indicating the status of his/her referral fund and a series of
vouchers that would report the number of claims paid or denied.
The method established by Medical Network One to compensate physicians
is the same today. The primary care physician receives capitation
and the referral physician is paid on a fee-for-service basis.
The burden of risk lies in the hands of the primary care physician.
The referral physician accepts no risk. The amount of capitation
allocated to the primary care physician by the managed care organization
is based on member months and it is age/sex adjusted. The actual
monies received by the primary care physician fluctuates since
the managed care organizations make financial adjustments called
retroactive-additions or retroactive terminations.
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Medical Network One contracts referral
physicians of all specialties from Allergy to Thoracic Surgery.
Currently, Medical Network One has a referral physician base of
close to 400.
In order to allow for access and
continuity of care, Medical Network One allows for primary care
physicians to refer to any physician with the stipulation that
(s)he is contracted by the managed care organization.
Payment to the referral
physician is made in a fee-for-service manner minus 10% utilizing
the Blue Cross and Blue Shield Trust Fee Screen. This reimbursement
model is called the Medical Network One fee schedule. Physicians
have accepted this method since 1981. In the event that a referring
physician does not wish to accept Medical Network One’s fee screen
then the prevailing Blue Cross and Blue Shield Trust Fee Screen
is provided.
Due to the increasing
number of inaccurate CPT/ICD-9 code correlation Medical Network
One has instituted a claim audit for all level 4 and 5 claim activity.
Those claims are pended for payment until documentation of medical
records is received. Those claims are then reviewed by a physician
advisor who makes the determination as to whether the appropriate
procedure code has been reported.
Medical Network One
staff has been directed not to guide the billing staff of the
referring physician regarding the appropriate CPT code to use.
This would be unethical and would violate Medical Network One’s
Compliance Policy.
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Primary Care Physicians may receive
the following funds if their referral account exhibits a credit
balance and if they have been participating with Medical Network
One for a period of time greater than 365 days.
Mid-year distribution of referral
funds (July)
30-50% depending on Board decision
based on claim activity
Year-end distribution of referral
funds (December)
30-50% depending on Board decision
based on claim activity
If Medical Network One exhibits a
profit in the management fund administered by the managed care
organization then primary care physician receives:
Withhold monies (retained by the
managed care organization)
Management fund disbursal based on
utilization (currently includes pharmacy)
In the event that Medical Network
One exhibits a loss in the management fund, Medical Network One
must pay 50% of the loss to the managed care organization within
a designated period of time.
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Medical Network One
does not recruit either overtly or covertly primary care or referral
physicians. There is also no written or verbal policy mandating
exclusivity. Medical Network One does have a participating physician
agreement that is on file in each physician’s chart. There is
also a continuation agreement that is executed whenever there
is a disbursal of funds.
The Director of Corporate
Affairs, Jessica T. Schell, is responsible for assuring both the
managed care organization and physicians affiliated with Medical
Network One that all contracted Medical Network One physicians
meet or exceed the guidelines provided NCQA by the managed care
organization.
Ms. Schell coordinates
all credentialing and re-credentialing processes including on-site
reviews and medical chart reviews. She is responsible for the
electronic retention of each physician’s application that is submitted
on a Michigan Association of Health Plans standard form. Additionally,
on file, are copies of all supporting documentation that are required
by the managed care organizations for either credentialing or
re-credentialing.
Ms. Schell also coordinates
all seminars that are scheduled for physicians or office staff
of the primary care physician or referring provider. She attends
all meetings pertaining to provider contracting and represents
Medical Network One at various meetings held at the managed care
organizations.
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The Claims Adjudication
Department at Medical Network One has five exceptionally trained
medical claim reviewers who have an extensive background in ICD-9
and CPT coding. Each reviewer has 10 years minimum experience
processing medical claims. In addition to the claim reviewers,
three highly qualified data entry staffers guided by Ms. Charlett
Braxton key in claim information. The team comprised of claim
reviewer and data entry contributes to the speed with which claims
can be adjudicated.
The Claims Adjudication
staff under the direction of Mrs. Maria Chisholm, Claims Manager,
receives specific training to assure accuracy when processing
claims and also to adjudicate claims in a timely and uniform fashion.
The Claims Adjudication staff meets monthly to review issues that
warrant discussion and also to assess the flow of processing claims.
It is the policy
of Medical Network One to adjudicate clean claims
within 45 days of receipt. In the event a claim requires supporting
medical documentation or it is incomplete it is then returned
to the billing provider.
Once adjudicated
claims are uploaded to the accounting system for either payment
or rejection. An EOB along with remittance are sent to the providers.
Concerns regarding outstanding claims are usually directed to
Mrs. Chisholm who then makes the determination if an exception
check should be issued.
The recent OIG Guidelines
specific to the establishment of Compliance Programs in physicians
offices and the imposition of fraud/abuse criteria have been provided
the staff at Medical Network One. With the installation of the
new Vantage Med software tracking of CPT abuse has been much simpler.
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The Quality Improvement
Program at Medical Network One is supervised by Elzbieta (Elizabeth)
Rozmiej, MD. Items routinely reviewed are:
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procedure requests
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provider requests
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referral requests
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con-compliance
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transfer request by primary care physician
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hours coverage including telephone messaging system
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denials
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meetings for staff and physicians
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Medical Network One
recommends that any of the primary care physicians listed on the
website be contacted. Reference letters are available from patients,
contracted and non-contracted providers and managed care organizations.
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Medical Network One does not render
direct or indirect medical treatment to managed care patients
and therefore has not acquired medical malpractice insurance.
Other liability insurance is being
considered.
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Medical Network One has not been
required to complete audits for either Medicare or Medicaid.
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Medical Network One
has an extensive employee manual. We encourage our employees to
bring questions, suggestions, and complaints to our attention.
Careful consideration is given to each of these in our continuing
effort to improve operations.
If an employee has
a problem, (s)he is directed to their immediate supervisor so
that the problem may receive prompt attention. If the problem
persists and it is not resolved after meeting with the supervisor
then a meeting is set-up with the Business Administrator or Executive
Director. If the problem continues to be unresolved a meeting
with the President may be requested.
No job is adversely
affected because an employee chooses to pursue resolution of a
problem. Conflict and problem resolution are important facets
of good employer/employee relations.
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Medical Network One will act immediately
upon receiving an inquiry from the managed care organization regarding
quality of care or access of care issues.
Inquiries from managed care organizations
are documented and then placed in the appropriate physicians permanent
file. If problems involving the same physician or patient recur
the Medical Director is notified. It is up to the Medical Director
to take appropriate action.
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Medical Network One
documents all grievances submitted by patients or physicians.
The Patient Inquiry or Physician Inquiry Form is completed and
placed into the chart of the primary care physician or referral
physician in question. The managed care organization is notified
of the problem which must be resolved within ten working days.
In the event the
problem is not resolved within ten working days, the Medical Director
contacts either the managed care organization or the physician
in question for an update.
As a result of frequent
infractions the Medical Director may initiate the process to have
a patient transferred from the care of the current physician or
request that the managed care organization render a verdict.
The Medical Director
may choose to initiate departicipation action against a physician
who has frequent complaints documented against him/her.
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All components of
Medical Network One’s information systems have been tested to
ensure that the Year 2000 did not cause any operational problems.
Each desktop terminal is Year 2000 compliant as well as the VantageMed
software and Solomon accounting software utilized for capitation
payment and claims payments.
Medical Network One
completed an extensive upgrading of its software in 1999 which
included the shutting-down of an archaic custom written software
system for claims processing that could no longer be utilized
in 2000.
The custom written
claims software is retained on two systems for archival reasons.
Currently, all claim activity from January 1988 to December 1999
has been dumped into Excel format to provide data for internal
use and possible distribution to pharmaceutical companies.
Medical Network One’s
accounting was also performed on the custom software program.
It too is no longer utilized. An accounting package was purchased
from the Solomon Company.
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The Credentialing
Committee of Medical Network One meets on a monthly basis or more
frequently when the need arises. Minutes of the meetings are kept
so as to assure that supporting documentations is available should
the need arise.
The Credentialing
Committee follows specific guidelines that were established five
years ago. The guidelines address policies routinely established
by managed care organizations for the credentialing and re-credentialing
process of physicians. Medical Network One follows generally accepted
standards taking into consideration NCQA guidelines and those
set-forth by the managed care organizations in the community.
In addition to credentialing physicians, Medical Network One has
established a policy to credential non-physician providers such
as physicians’ assistants and nurse practitioners.
It is also the responsibility
of the Credentialing Committee to review any quality of care or
access of care issues brought up by a managed care organization,
peer physician or patient. Cases requiring review are completed
in a confidential manner with final disposition being sent to
the physician and managed care organization. If required, the
National Practitioners Data Bank may be notified or queried.
All steps taken by
the Credentialing Committee are done so with the approval of the
parties involved. The process is outlined in the Credentialing
Committee Guidelines and approval is granted through the signed
participating physician agreement
Al Juocys, DO
Wayne Meech, DO
Elzbieta A. Rozmiej, MD
M. Susan Bratkowski, RN
Jessica T. Schell
Margaret Kucinski, RN
Ilene Latasiewicz, RN
Ewa Matuszewski
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- PCP
Directory
-
Detailed list of all Primary
Care Physicians
- MNO
Directory
-
List of all employees and telephone
numbers
- Board
of Directors
-
List of all board members
