Payer pricing transparency: Next generation steps

Beware of broad terms about what the payer may publish, such as “Provider agrees to be included in our online and paper provider listings.” That used to mean your name and contact information, and you’d want that published but now it could mean something much different.

These terms initially mean that it’s time that the contract negotiations include a frank discussion with the payer about what products it offers and what information it plans to make available to enrollees.

If the payer is compiling its own data, ask where it gets the data. Are they from a Web site, a state hospital association, or CMS? Or, is the payer creating them?

Perhaps the payer is basing its rankings on your own coded claims. If so, ask yourself whether you’re including all of the information to make the payer’s picture of your organization as accurate as possible.

If you come out on top of the quality rankings and you’re coding your claims as completely as possible, then maybe you really are the stellar provider in your community, and patients should take this into consideration. But when the data [are] assembled by someone else and they are responsible for making decisions about what is included and how they rank, you must make sure that [they are] accurate.

About the Author

Reed Tinsley CPA

This article is written by Reed Tinsley, a Houston, TX-based CPA with over 30 years of experience advising physicians and medical practices across Texas and the United States. Reed holds certifications as a Certified Valuation Analyst (CVA), Certified Healthcare Business Consultant (CHBC), and Certified Financial Planner (CFP), specializing exclusively in the healthcare sector. He is a published author, nationally recognized speaker, and trusted advisor to physicians on accounting & tax, practice management, and financial planning. Schedule a Free Consultation.