Payer contracting – Get back to basics

Sometimes the more challenging things get, the better it is to get back to basics. Perhaps the best thing you can do to manage your frustration is return to your payer contracts and try to get what you want out of them. When reviewing your payer contracts, analyze the following:

1. How important your practice is to the payer’s ability to conduct business locally. If you have reason to believe that your practice is important to the payer's business, you may be able to renegotiate higher rates or reimbursement.

2. How much business your practice does with the payer. Decide if you are willing to lose that business if the renegotiation accord is not met.

3. What is objectionable and what you would like to change about the contract.

4. The possibility of affiliating with other providers to gain market share and improve your negotiating position. 

When deciding whether to renegotiate or scrap a contract, consider the following:

1. Timeliness clauses — if an insurance company has a timeliness clause (for example, if the company requires you to submit charges within 30 days of service) you should consider countering with requiring the company to adhere to the same timeliness for recoupment (when an insurance company deems a previously paid benefit as unnecessary and takes the money back).

2. Carve outs — if carve outs (when an insurance company lowers its rates to cover lower income families) in the payer’s plan are affecting your bottom line, you may want to renegotiate or terminate.

Throughout the year, take notes on payers' performance:

1. Were they easy to contact? 

2. Did they reimburse on the agreed upon rates? 

3. Do they respond to your questions? 

4. How willing were they to disclose the fee schedule used to reimburse your practice under the terms of your contract? 

5. Do they fully disclose their payment policies? 

6. How satisfied are you with the claims appeals process? 

7. How satisfied are you with the promptness of claims payments? 

8. How transparent are the cost and quality measures used for physician rating and/or pay-for-performance programs? 

Have questions? I’m here to help.