Negotiating Medical Practice Payer Contracts to Your Advantage

Rapidly Changing Medical Reimbursement Environment :

Over a period of time, considerable changes in complexity and scope of contractual negotiations and agreements with federal, state, and private insurance organizations have been experienced by clinics and hospitals. At present, most of the practices accept whatever the insurance companies offer, rather than resorting to implement insurance contracts on a win-win basis.

This results in losing out on additional revenue to the tune of 15%. Successful renegotiation of insurance contracts results in a typical yield of 10-12 %. This is money that is available but lost because most of practices do not have the expertise to renegotiate their insurance contracts. The medical practice not only suffers from a bad insurance contract, but doesn’t even know what’s in the contract.

Expert Opinions :

Brian Workinger, business solutions consultant at Craneware, a specialist in software for health care billing, auditing, chargemaster management and medicare compliance, emphasizes “the need to compare reimbursement rates of insurance companies, rates of nearby hospitals, and know the clinic’s market shares in medical services. This information will help to negotiate with the insurance companies.”

According to Kyle Kobe, principal at Equation, a healthcare consulting firm, “it pays to do an extensive homework and understand the existing contracts, know market contract rates, and determine how the existing contracts can be improved.”

Mary Ely, director of physician relations at Greater Baltimore Medical Center (GBMC) and head of managed care and negotiations with insurers, adds that “there is a dire need to claim denial histories, Medicare fee schedule changes and insurance contracts, and follow up by extensive research on existing contracts. “

Multi-pronged Approach :

MedicalBillingStar has developed a sophisticated model that analyses existing and proposed contracts and ensures that the hospital management understands the financial and operational implications of existing contracts, as well as the implications of new contracts and/or proposed changes. We offer effective insurance contract negotiating services to the medical practitioners. We:

• A. Help the clinic/hospital to maximize the profitability of each contract. We have developed sophisticated analytic methodologies, including modelling of contract to identify underperforming contracts.

• B. Guide medical practitioners to process claims based on our knowledge and experience on the techniques used by insurance companies. We have in-depth knowledge of insurance contracting, including complex reimbursement terms, adjudication rules, and trends in public and private insurance policies.

• C. Develop the necessary tools to work out contracts with insurance companies.

• D. Help establish contacts with key personnel in each insurance organization.

• E. Identify key insurance companies related to the medical practice and the top 20-25 codes billed.

• F. Contact each insurance payer and find current reimbursement for these codes.

• G. Present comparison of actual reimbursement and existing payment norms to the clinic/hospital management and recommend the insurance companies that are to be contacted for renegotiations.

• H. Hard bargaining at the negotiating table: Approach the recommended insurance companies, and give as much details as possible about the medical practice, team of doctors, diagnostic, treatment, and rehabilitation processes, and so on.

• I. Avoid being caught off-guard ! Help closely scrutinize finalized insurance contracts to identify language or hidden agendas which need to be eliminated. Understanding the health insurance language is very helpful, especially when each insurance company conveys the contract language in its own format.

• J.Avoid dangerous evergreen trap! Help in avoiding “evergreen clauses” related to reimbursements, which implies that the insurance companies continue to pay the same rate to the medical practice, even when at a later time the rates are raised, paying more to other practices. We renegotiate a fair fee schedule. We stay tuned with the latest rates, which insurance companies are not too eager to give out.

Tie-up with MedicalBillingStar… We save your time and money with better payment and fairer insurance contracts…