2. Are the applicable fee schedules annexed to the contract? You should have access to the health plan`s fee schedule for all services you offer. Submit at least a list of the services you provide in your practice and request that the fee schedule amounts for these services be included as an appendix to the contract. If the health care plan is not prepared to disclose eligible amounts, determine why it is withholding the information and proceed with extreme caution. 3. Does the contract include a “most-favoured-nation clause” that requires you to offer the health care plan the lowest or cheapest rate you have negotiated with a network of providers or a payer? Your contract rates with other health plans or payers are confidential and protected by copyright and should not apply to further negotiations. Consider requesting that this wording be removed from the contract altogether. Other suspicious formulations that need to be removed from the contract include provisions that allow the health care plan to offer multiple discount agreements or fee plans to its customers. Each payer and each group of employers should be bound by a fee schedule. Does the contract include other incentives for quality, cost-effective care or medical management? How are these programmes developed and monitored and how often does the GP receive an update on progress? In addition, seek the physician`s advice in developing incentive programs, carefully review the program criteria to determine if the goals are achievable, and determine if the health care plan provides staff to help the physician analyze and interpret the data. You should also prepare a different and shorter stack of letters – one for each of the H/R departments of the employers in charge of the insurance company in question. They will want to point out that the insurance company they have contracted with does not provide the coverage they are likely to expect.
Name the number of their families who will lose their medical home and high-quality pediatric care. Often, a worried call from a large local employer is enough to bring an insurance company to the table. But don`t stop there, Brauchler said. Look at your rent, staff health insurance and your employees` salaries. Have they also increased over time? “It should be an immediate win if your own health plan that you provide to employees hasn`t given you an increase in the payment rate — especially if you`ve seen premium increases in the last three years,” she said. “Where does the annual premium increase go if you`re still paid according to a previous year`s fee schedule?” 5. Are the health care plan requirements for access to and retention of medical records appropriate? Does the contract wording limit access to medical record information to the minimum necessary and not to the entire medical record? Limiting access to medical records to the minimum necessary not only protects health information, but also contributes to the efficiency of your practice, as providing copies of the medical record can be costly. Does the health care plan require additional primary care physicians in your geographic area? It is advisable to start discussions with the representative of the cost object 120 days before the end of the contractual period. It helps tremendously if the communication is led by someone in the health care plan with whom a business relationship has been established.
Commercial payers do not automatically reward physicians for being loyal members of their networks. Doctors need to ask for higher payment rates, said Marcia Brauchler, MPH, CPC, president and founder of Physicians` Ally Inc., a health consulting firm in Littleton, Colorado, who spoke at the CSLA HEALTHCON April 8-11 in Orlando, Florida. Does the contract include a requirement for timely payment? It is reasonable for you to expect your claims to be processed and paid within an acceptable time frame, usually within 30 days. If your state`s insurance department has passed immediate payment laws, your contract must state that the health plan or its payers comply with all applicable regulations for immediate payment. If your state`s immediate payment regulations include exclusions such as workers` compensation claims or employer self-funded claims, you can also discuss adding contractual language for those claims with immediate payment. Prioritize the terms and dates of insurance contracts. Most plans renew automatically unless you request changes. Before you invest too much time in reviewing contract wording and legal clauses, you need to gather as much information as possible about the health care plan and its strategic plan for your community. This information will help you determine if your practice is operationally, financially and ethically compatible with the health care plan. Review the information on the health care plan`s website to determine its mission, vision and values. Health plan websites often contain other important information, including the financial performance of the health care plan and previous data from the Health Care Plan Employer Data and Information Set (HEDIS) www.ncqa.org/tabid/59/Default.aspx).
The day you start sending the letter to patients, Hart suggests reminding patients of your remaining payers who are late for clinical services. For example, in most pediatric practices, half of adolescents are late in their well visits. Get in touch with these families and make sure these patients come to catch up on their care. Not only are you providing a valuable service, but you are also filling the short-term void in your schedule. And since you`ve done your homework and given up on the lowest-paid insurance company, you don`t need to bring in so many patients from other companies to fill the void. For example, if the business you lost paid you 30% less than the remaining payers, you only have to restore an average of 70% of visits. If you have informed the families well in the letter you send, some will take the opportunity to switch to an insurance provider on your accepted list. You keep these patients, and the insurance company you abandoned will lose significant revenue. You will actually find that you will generate more revenue with fewer visits.
Before starting negotiations with a health plan, identify all the levers you can use in the contracting process. This task is easier said than done, and timing can play an important role. Also, you need to understand how the health plan handles fee plan changes. Contracts often refer to annual fee schedule updates or updates due to changes in CPT or HCPCS codes. Learn more about the health care plan`s guidelines for mid-year changes to the fee schedule. Can it change the general method of the fee schedule throughout the contract year or simply adjust the eligible amounts on a code-specific basis? If medicare retains the ability to make mid-year adjustments to the fee schedule, you should also consider asking for the option of negotiating mid-year changes from the physician`s perspective. Before negotiating with payers, you can do some research and know your internal data to prove beneficial. HEALTHCON offers training sessions and networking opportunities for medical programmers, billers, payer representatives, practice managers, lawyers, physicians and other healthcare professionals. 1.
Does the health care plan require that only contract providers be able to offer evening and weekend calls? If so, will it work for your practice? Also check the health care plan`s policies regarding the use of physician assistants (PAs) and advanced registered nurse practitioners (NAPs). .
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