(305) 273-9100
As a dedicated medical provider, your primary goal is to deliver quality care that helps maintain the health of your patients. As the owner of a successful practice, it is also important to do so cost-effectively.
That is why HMOs (Health Maintenance Organizations) were formed in 1973 – to provide an alternative to traditional fee-for-service healthcare delivery and make affordable healthcare more accessible to patients, all while ensuring that healthcare providers maintain their bottom line.
Like all federal mandates, however, it is critically important that providers understand and adhere to HMO regulations, as non-compliance could result in fines, penalties, lawsuits, or recoupments. Individual providers could even lose their medical licenses if they fail to follow the law.
Here’s what you need to know to protect your practice and your professional reputation.
An HMO Overview
The first step in ensuring HMO compliance is to understand what an HMO is. The Centers for Disease Control and Prevention (CDC) defines an HMO as “a health care system that assumes or shares both the financial risks and the delivery risks associated with providing comprehensive medical services to a voluntarily enrolled population in a particular geographic area, usually in return for a fixed, prepaid fee.”
There are several HMO model types:
- A group model HMO contracts with a single multispecialty medical group to provide care to its HMO members, either working exclusively with the HMO or providing services to non-HMO patients, as well. The group is paid a negotiated per capita rate by the HMO, the amount of which is distributed among the group’s physicians, typically on a salaried basis.
- An individual practice association (IPA) is comprised of a group of independent practicing physicians who maintain their own offices and band together for contracting their services to HMOs, preferred provider organizations, and insurance companies. As such, the group can contract with and provide services to both HMO and non-HMO plan participants.
- A mixed model HMO combines features of two or more HMO models.
- A network model HMO – including single or multispecialty groups – contracts with multiple physician groups to provide services to HMO members.
- A staff model HMO is a closed-panel health maintenance organization in which patients can receive services only through a limited number of providers, and the physicians are HMO employees.
How to Become HMO Compliant
In order to be HMO complaint, your organization or practice needs a healthcare compliance plan that includes written policies, procedures, and standards of conduct. If it is a large practice or hospital, you should focus on managing risk areas, such as:
- Billing for services not rendered
- Upcoding
- Unbundling
- Duplicate billing
- Claim development and submission process
- Medical necessity
- Anti-kickback and self-referral concerns
- Bad debts
- Credit balances
- Record retention
Your healthcare compliance plan should also consider areas of vulnerability based on frequent internal audits and Comprehensive Error Rate Testing (CERT). CERT is designed to calculate a national improper payment rate and contractor- and service-specific improper payment rate that is based on a statistically valid random sample of Medicare fee-for-service claims. Using this information, you can identify potentially high-risk areas and then conduct a risk analysis to ensure that your practice is compliant.
Ongoing auditing and monitoring are advisable as a means of assessing operational and financial risk, as well as ensuring that your employees are following written policies and procedures. However, an effective alternative to these complex and time-consuming measures is to outsource them to a support services provider who can take care of your health plan and regulatory compliance tasks, while you focus on delivering the best possible care to your patients.
Compliance Support in Central and South Florida
At Premier Physicians Support Services, our integrated team of experts has more than two decades of experience in providing administrative services and management solutions – including health plan compliance – to primary care, family medicine, pediatric, and internal medical specialty practices throughout the state of Florida. Our goal is to help your practice save time, money, and energy while improving patient care.
To learn more about our exceptional organization and how our services can greatly benefit your practice, contact Premier Physician Support Services today at (305) 273-9100.
