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Negotiating Payer Contracts




Do you review every clause of your payer contracts before committing, or do you simply sign them without giving it much thought? Know exactly what you are getting into before signing on the dotted line.

Payer-provider contracts are crucial to being compensated for your work, but the insurance company does not hold all the power. Do your homework, and you will have a better chance of cutting a deal that is in your favor.

Diagnosis: Problem Payer

Start by taking a good look at the big picture: Which insurance companies make your contractual obligation worth your while, and which barely cover (or do not even come close to meeting) your costs? Once you know this, you can focus on rectifying the contracts that are not working in your favor.

Healthcare consultant Jeffrey B. Milburn, MBA, CMPE, writing for Modern Physician, recommends you calculate how much each insurer has paid you per visit during the past year. For each insurer, divide the total revenue by total visits; this will produce an average dollar figure for each patient. Repeat this step for each insurance company, and compare the results. The companies whose compensation is below par should catch your eye right away.

Payment per patient is the first — but not the only — factor to consider. For instance, a particular insurance carrier’s payment levels may appear to be in line with all the others, but the company may be responsible for most of the administrative headaches — such as denials, subsequent appeals paperwork and lost claims — that inconvenience your office staff and patients alike.

Decipher the Lingo

When you review a payer contract, be sure you fully comprehend the contract language. Understanding how the company defines important terms and spells out key provisions is vital to structuring an agreement both parties can live with.

Charles E. Rhoades, MD, writing for the American Academy of Orthopaedic Surgeons online practice management center, urges physicians to examine the wording of terms relating to payments and covered services. One of the most common terms that can produce grief is “usual and customary” — the fee on which a company bases payments. Does this mean the amount you normally charge for service? Or the average fee charged by other practices in your area? Or a figure generated by another organization? If in doubt, ask.

Be aware of amendment provisions, which usually state that you agree to abide by any changes to the company’s rules and regulations, but do not spell out the carrier’s obligation to inform you of these changes. Make sure that your written consent is required for amendments to the agreement, that you will be notified within a certain time frame, that the notification will be sent with proof of delivery, and that the time period for you to accept or reject changes is specified.

Look carefully at the contract’s provisions for down coding (i.e., changing the codes submitted by your staff) and changes to the fee schedule. Ideally, your contract should say that the payer may not make arbitrary changes to current procedure terminology codes without notifying you in writing by certified mail or another method with proof of receipt.

Finally, review the contract term, which may be tied to the anniversary date of the contract, and termination rules, which may state that the contract will be automatically renewed if you do not request termination well in advance, typically 180 days.

Assess Your Worth

Objectively gauging the value of your services to the community lets you know how much leverage you have in contract negotiations. Are you the only physician in town practicing in your specialty? This situation makes it easier for you to ask for reimbursement increases or other compromises on the insurance company’s part. Conversely, is yours one of dozens of similar practices that all accept the same insurance plans? In this case, rejecting a payer contract out of hand may affect your ability to compete in your local healthcare market.

Let’s Make a Deal

Now that you understand your reimbursement levels and bargaining power, you are in a better position to open negotiations with your problem payers.

In its white paper “How to Negotiate Insurance Contracts,” accounting and consulting firm Renkenen recommends scheduling a time for each insurance company representative to meet with you in your office. Show the representative the reimbursement comparison you compiled, and explain that you are prepared to cancel the contract unless the company presents you with a satisfactory new agreement. To make your position perfectly clear, prepare sample letters explaining to your patients that despite your best efforts to renegotiate an equitable contract, you are no longer able to accept the company’s insurance plan.

Keep in mind that insurance companies tend to resist making changes to their standard contracts, but they should be open to your tacking on addendums that address areas of special concern.

Stick to your guns, and wait. The closer you get to the contract termination date, the more willing the payer may become to make concessions.

Be Prepared to Say No

The bottom line: If an insurance carrier offers you a contract that you find unacceptable for any reason, you have three options. You can grit your teeth and decide to live with it, reject it, or try to change it.

If you are unable to alter a payer contract to your satisfaction, turning it down may be the wisest course. Sticking it out with an objectionable insurance carrier is not only a drain on your finances but also depletes your employees’ energy and enthusiasm. Remember, if you do decide to cut a carrier loose, you can still see their insured patients out of network. These patients usually have a higher copayment or deductible, but you may be surprised how many prefer to see you regardless.


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