Feature
Navigating the labyrinth
An IR's perspective on the referral process By Evan Harris, MD
S
everal years ago, I left my hospital-based IR practice to run vein centers for a large regional organization. Having learned about this opportunity through the SIR Annual Scientific Meeting, I was excited by the benefits it would unlock: a work–life balance, no call weekends and the support of a large group when dealing with the never-ending struggle with insurance company credentialing and contracting.
As with some of my former colleagues, I hoped that joining a large group would help lower the likelihood of plan exclusion or of ending up in a financial disadvantage in contracts and would increase referral opportunities. However, I soon learned that even with this added clout behind me, several plans remained out of reach as insurers claimed their panel for IR was full—whatever that means.
Like many aspects of the credentialing, contracting and referring process, this struck me as unnecessarily difficult and exclusionary. If, as a provider, I am willing
to accept the payer’s fee schedule, why limit the number of providers if not to simply control and limit patient access?
After setting out on my own, I quickly realized how fortunate I had been in my former practice, with the constant flow of hospital-based referrals. Though I developed good relationships with local practitioners, I soon found this was not enough to gain access to their patients. Many of these potential referral groups had coalesced into even larger restricted networks in order to add further benefits from economies of scale for credentialing, contracting and referrals. Referrals contained within their networks of providers were strongly encouraged and incentivized.
Much like the restrictive nature of exclusivity contracts, these provider network integration arrangements limit member providers in certain specialties based on organizational needs. “Desirable” specialty providers often overlap in services provided—there were typically several vascular surgery
groups, cardiology groups and various endovascular providers in addition to the exclusively contracted diagnostic and interventional radiology group. Network organizations that were affiliated with entities that owned hospitals and surgical centers also provided special membership status to other network organization members and a back door to access for those practices that could fill beds and operating rooms. It became clear that this system was not interested in allowing membership to an independent IR outpatient vein center practice.
Following the path of least resistance, I pursued inclusion in restricted networks that didn’t already have vascular practice partners. This approach initially seemed promising: the network appeared genuine in their review of all potential members while seeking practices with proven service excellence. However, they did not have the internal resources to establish their own criteria for specialty distinction and instead relied on insurance industry metrics for practice assessment.
SIR recently launched a carrier advocacy program to prevent the enactment and modification of coverage policies that adversely affect SIR members. Adhering to HIPAA laws and regulations, please use the carrier advocacy form to submit your claims denial report for any IR service.
tfaforms.com/4743899
sirweb.org/irq | 27
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40
