4 Ways to Get What You Want from Payers

Payers just keep getting bigger and bigger, and it will be harder for eye care leaders to stand their ground during payer contract negotiations. But have no fear—we have tips that will help you prevail and keep your financial future strong.

Payers with Plans to Bulk Up

As you likely know, CVS—a drugstore chain and prescription drug insurer—has announced earlier this month that it plans to buy Aetna in a $77 billion acquisition. If approved, it would be the largest health insurance deal to date. Of course, it might not happen, just like the Aetna-Humana and Cigna-Anthem deals that were blocked this year by Federal judges amid antitrust concerns. This deal is different because it’s a vertical merger—CVS and Aetna aren’t competitors—so the real effects on consumers and providers remain to be seen. And that’s a good thing. When it comes to negotiating with payers, providers (especially smaller practices) already have a weaker hand. Below, some tips to hold your own:

Know Their Standard Format for Contracts:

Most payer contracts organize their information similarly. Practice management consultant Marcia Brauchler has seen a lot of them. “It’s amusing to note the number of physician obligations versus the health plan’s obligations,” Brauchler notes. “I’ve seen 55 professional obligations to three health plan obligations.” Yikes.

You may hear payer reps say these two statements, and they are never true, says AudioEducator speaker Melody Irvine.

  • “We can’t possibly do that.”
  • “We have one fee schedule for all providers.”

If you hear these statements during negotiations, push back.

Have Multiple Staffers in Your Practice Review the Contract:

Some doctors don’t realize what a difference multiple contract reviewers can make, Irvine says. Involve your sharpest biller or coder in contract review. Folks in your back office have spotted the ‘usual suspects’ already, and they’re more familiar than you might be with sneaky payer tricks.

Eyes Open: The contract might slip in modifier policies involving -25, -51 and -59 that could slash your reimbursement. If an expert coder or biller reviews the contract, she will spot this kind of trick and alert you to potential cash flow challenges.

Keep Copies of All Your Contracts in One Place:

If you’re currently contracted with the payer, compare language year over year before signing again, Irvine suggests. Some payers try to slip in new terms at renewal that are unfavorable to you, hoping you and your office staff won’t notice.

Eyes Open: Your review team should scrutinize the most recent policy manual before signing an agreement. The manual often reveals much more than the contract about revenue-crucial policies for credentialing, claims submission, coding policies, appeals, and grievance procedures, Irvine says.

Make a Checklist of Must-Haves and Deal-Breakers:

We have some key checklist items here.

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