A high denial rate for ER visit claims may be an indicator that a plan needs to do a more effective job to encourage appropriate alternatives. A plan should be able to provide outcome statistics to support a decision to include a specialty provider in its network. Health plans use various criteria to recruit physician and hospital providers. For example, board certification is often used as one requirement for physician credentialing. You should ask about the plan's criteria for selecting physicians and hospitals and also how often the plan checks to see that the provider credentials are maintained.
Plans differ in the way physicians are compensated.
Some plans may provide incentives to reduce the use of services. Some plans have developed programs to improve physician performance. Member satisfaction surveys are sometimes used in the formula to determine compensation for a primary care physician. You should ask if your plan uses these or other programs. The Department of Health approves complaints or grievance procedures for HMOs as a condition for receiving a Certificate of Authority to operate in Pennsylvania.