Practice Management

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Due Diligence

  • Is the MCO financially stable? Check with your state insurance and/or HMO Commission.
  • What is the MCO's reputation in the physician community and with the providers? What other cardiologists participate with that MCO? Determine if you complement or compete with those other practices.
  • Can the MCO provide the volume of patients necessary to make the plan profitable? Is the MCO willing to share its utilization data?
  • Is the anticipated reimbursement method acceptable? Find out when and how you will be paid. Are there withholds, holdbacks, or financial penalties that should be incorporated into your analysis of those payments?
  • What is the MCO's reputation for timely payment of claims?
  • Does the MCO contract with the hospitals and surgery centers with which you are affiliated? Ask if it dictates which services must be performed in specific locations.

Action Steps

  • Review managed care contracts for detailed information concerning the actual scope of the type of services you render. Ask the managed care payor for a detailed list of services for which you will be responsible.
  • Obtain utilization data from the HMO showing the historic frequency and type of services specific to cardiology that the HMO's patient population utilizes. Compare this data with an analysis of the range and frequency of the same services you generate internally for your practice to see how it compares to your current practice, assess how your practice might react to those likely utilization differences.
  • Identify and eliminate procedures or services that you are not able to provide, such as expensive or extensive clinical procedures, services beyond the scope of your practice, or those that require a large amount of time. You may want to negotiate these services and procedures as "carve-outs", enabling your practice to receive fee-for-service reimbursement. You may then be able to subcontract those services to specific providers at predetermined rates, while still assuming the role of providing the general and full range or care for your specialty. This may reduce financial risk and increase income.

Contact membership@acc.org; 800-253-4636, ext. 5603; 202-375-6000, ext. 5603

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