Transcript Using Data to Renegotiation Your Payer Contracts April 25

2015 User Conference
Using Data to Renegotiation Your Payer Contracts
April 25, 2015
Presented by:
Aimee Heckman
OP 15 Billing Manager
General Session
Using Data to Renegotiate Your Payer Contracts
▪ PLAN
▪
Track and monitor your contracts
▪ DO
▪
Value current contracts by assessing fee
schedules
▪STUDY
▪
▪
Analyze current contracts in detail
Identify contract improvements needed from payer
▪ACT
▪
Renegotiate
2015 Office Practicum User Conference
PLAN
Monitor your contracts
▪ Keep a master spreadsheet that shows which
contracts are due for review
▪ Monitor spreadsheet to determine date for
opportunity to improve your contract
2015 Office Practicum User Conference
PLAN
2015 Office Practicum User Conference
PLAN
Set a Timeline to Renewal
2015 Office Practicum User Conference
DO
Value current contracts
▪ Use Office Practicum reports or spreadsheet software
such as Excel or Open Office to create a report to
compare procedure codes and payments from each
payer
CPT Code 99213
Payer 1:
Payer 2:
Payer 3:
$50
$60
$70
CPT Code Payer 1
Payer 2
99213
$50
Payer 3
$60
$70
99214
$55
$65
$75
2015 Office Practicum User Conference
DO
2015 Office Practicum User Conference
DO
▪ Create a second report that compares
average dollars deposited per visit from
payers
▪ Total the number of visits per insurance
company and use that number as the divisor
of the total revenue dollars deposited for
those visits
2015 Office Practicum User Conference
STUDY
▪ What is right about your current contracts?
▪ What do you still need from the insurance
company?
The greater danger for most of us lies NOT in
setting our aim too high and falling short; but in
setting our aim too low and achieving our mark.
~Michelangelo
2015 Office Practicum User Conference
STUDY
Know your current contract and amendments
▪ Contracted with Self Funded, Leased Network or
Insurance Owned Network
▪ Fee Escalators - what % and how often
▪ Carve Outs
▪ State Laws re: timely payment and timely filing
▪ Are you with a Clinically Integrated Network or ACO
whose contracts can replace/void your agreement
▪ Notice required for contract amendments, term and
termination
▪ Payment Policies
2015 Office Practicum User Conference
STUDY
Do you want a quality or value based contract?
▪ What is your leverage?
▪
▪
▪
Size
Low $$ utilization
Clinical Quality
▪ Medical Home
▪ High Immunization rates
▪ Low antibiotic usage
▪ Asthma and Obesity
2015 Office Practicum User Conference
STUDY
Value Based Contracts
▪
▪
▪
▪
▪
Vary by geography
Can be lucrative
Don’t want skin in the game
Local Managed Care hurting on HEDIS?
Peer group can’t manage and lots of referrals
and hospitalizations?
▪ New HIN everyone wants you to use?
2015 Office Practicum User Conference
ACT
Renegotiate
▪ Goal
▪
▪
What you want to achieve in your contract
What result would THRILL you not just satisfy
▪Bottom Line
▪
▪
What you absolutely MUST agree to
If bottom line is not met, be ready to walk away or
have a great poker face!
2015 Office Practicum User Conference
Steps to Success
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
Set your bottom line
Consider what the payer needs from the practice
How the practice meets those needs
Be the first to set the contract offer; Have a plan for your counter
offers
We will do this for the payer and you will do this for us
Have your data ready! Fee comparisons - Member Facts - Costs
Play smart and confident; Do not appear uninformed or too
aggressive
Start with the easiest mark, one that you are sure will be met
with YES or NO
Make counter proposals incrementally, do not go straight to the
bottom line
Know when to close the deal and push for effective date as soon
as possible
2015 Office Practicum User Conference
Changes You May Wish to Make
▪ Establish spreadsheets or reporting method
to track and monitor your insurance contracts
▪ Consider Value Based Contracts
▪ Maintain Awareness of Payer needs for their
members
2015 Office Practicum User Conference
2015 Office Practicum User Conference
REFERENCES
For more information on this subject:
Join PPMA and visit the Practice Support page at
http://www.aap.org/practicesupport
Insurance Contracts
http://www.aap.org/en-us/search/Pages/results.aspx?k=Insurance%20contracts
2015 Office Practicum User Conference
We want your feedback!
2015 Office Practicum User Conference