Managed Care Organization (MCO) Insists that Urgent Care Physician has Hospital Admitting Privileges

"What do I do, if the managed care organization (MCO) insists that I have admitting privileges to a hospital? I am an emergency physician, and I have never had admitting privileges." This question came up in my talk (available on CD; to order contact bburress@ucaoa.org) yesterday at the Lake Tahoe UCAOA Annual Convention, a great success with over 350 attendees and 52 vendors with helpful products or services for urgent care centers.

It is important to get face-to-face with the managed care organization (MCO) representative, who is actually empowered to make decisions. It is key NOT to ask your rep, “Who will really make this decision.” Instead, ask the rep, “Before you make this decision, who will you want to consult with.” Answer is—the person who actually makes the decision. Then, you arrange for a meeting with that person in the offices of the MCO. Explain to the rep that:

• You operate an urgent care center,
• Urgent care centers are exclusively outpatient specialists,
• Few urgent care centers ever directly admit to the hospital,
• You always admit to a specialist, the PMD or to a hospitalist.
• Thus, admitting privileges are irrelevant.

If they still insist, then maybe you should see if courtesy privileges will suffice. If they still insist, (i.e., they don't give you enough respect to listen to your point of view), then you might try to get admitting privileges. If you can’t get admitting privileges, and the MCO won’t budge, then bad news; what is probably happening is that you are dealing with an MCO that doesn’t think it needs you (or maybe even any urgent care center) as a participating provider.

Still the managed care organization has no interest in contracting. Time to give up? No! Now you need to explain the value of urgent care centers in:

• decreasing expensive ED visits,
• improving client satisfaction,
• covering the medical needs of the walking well (which are the only sources of profits for the MCO).

Still the managed care organization has no interest in contracting. Time to give up? No!

Now you need to find or land a large (larger the better) employer that:

• is thrilled with your services
• you have visited with face-to-face and you have a good relationship with
• and uses the MCO in question for covering healthcare for it’s employees.

Ask the HR rep, if he or she is willing to send a letter to the MCO, stating:

• That having your urgent care center on their panel is “very important” for a continuing relationship with the MCO. Translation: “Get the urgent care center on the panel, or you risk losing our account."
• Next, type up the letter, email it to the HR rep, and thank the rep for being willing to send this letter under the company letterhead

Still the managed care organization has no interest in contracting. Time to give up? No! Just keep providing great service to walk-in patients and for corporate clients. Always, make sure that you give a typed letter (with stamped envelope) for any employer or patient to sign, expressing dissatisfaction that your urgent care center is not a participating provider with the managed care organization. If you can mail the letter yourself, do it. Over time, your urgent care center will win, because you are providing an important cost-effective alternative to the hospital ED. Whether the MCO knows it or not, the MCO needs your urgent care center.

More information on managed care contracting for the urgent care center is available on CDs of my two talks at UCAOA-2006, which are available through the Urgent Care Association of America (all proceeds are kept by UCAOA to benefit the organization). Contact bburress@ucaoa.org to get an order sheet for the CDs.

Good luck!