It's 10am. Do you know where your managed care contracts are?

When I was a child, at 11pm every night, the news would start. But just before, a PSA would come on and say "It's 11pm. Do you know where your children are?" Parents would get up and check on the kids to make sure one didn't elope out the bedroom windows. I usually got busted reading a book with a flashlight under the covers. I never eloped out the window.

But at any given moment, I can walk into most physician practices and ask to see a copy of their managed care contracts and usually, nobody knows where they are or when they were last reviewed, if ever. When I walk into established traditional Medicare / Medicaid / Managed Care practices to transition them to concierge medicine or direct pay practice business models, I ask to review their managed care contracts. I also ask for some basic practice demographics and statistics, including:

1. A report of age, gender, zip code, insurance plan(s), and key diagnoses and CPT code YTD frequencies
2. A report without names showing that shows me the current aged trial balance
3. A report of each CPT code price list and maximum allowable fees by contract

It doesn't matter what software they are using: Greenway, Athena, ECW, CareCloud, Kareo, iSalus, NueMD, and others, they have no clue how to print the reports for me. Years ago, in an early stage of my career, as a practice manager, I could get this information in 30 minutes out of most report generation modules in most any practice management software. I used these reports to give report to the physician owners and partners in my monthly administrator's meeting with the physicians. In the past year, only one practice held such meetings and then only quarterly. No wonder so many medical practices are in such trouble and misery. Is there no place to learn how to be a practice administrator? I guess not!

For one practice conversion, I am still awaiting both their contracts and their data since my September 12 request. Their onsite consult was October 21, I just received the contracts but still no practice data.

Without access to contracts and a contract management system (even an Excel or Google Spreadsheet will do!) how can you know the following:

• The exact amounts you should expect to be paid and or write off for services, supplies and procedures
• The lowest amount you should bill in a "lesser of" arrangement
• The reasons a plan can decide not to pay and how to appeal and to whom
• To whom you should direct Notices of Breach when payments are late or incorrect
• When the contract renews or expires and if there are evergreen terms or fee escalations attached to anniversary dates
• What the minimum advance notice is to quit the contract
• Reasons accepted for termination (for cause, for no cause, or material breach)
• How to handle disputes
• If the online provider manual is incorporated into the agreement with advance tacit approval from you to any changes to the manual without amendment or specific notice - which could affect your reimbursement or your ability to transition to DPC or Concierge
• How coordination of benefits will be calculated, if at all
• Which other plans have access to your discount through plan-to-plan affiliation(s)
• How multiple logos are treated on a plan membership card
• How cross coverage physicians will be paid
• Time limits that govern how quickly you must see the patient or grant appointments for new and established patients and for routine or urgent care access

I also need to see IPA, ACO and PHO agreements, if any because sometimes managed care plans are negotiated through these entities, but the IPA, PHO, and ACO contracts don't specify the details I listed in the bullet points above. That means I have to ask the IPA, PHO or ACO and often, the doctor doesn't want to tip these entities off that he or she may be transitioning to concierge or DPC so how the heck can this data be obtained to complete the analysis? It can't. That's dangerous and very risky. Deciding to move forward with the transition without this data could get you sued for breach of contract. Then, all the time and money you might have set aside for rebranding and marketing goes towards legal defense and legal distractions.

If the consultant you've contacted to help with your transition does not examine these points and statistics of your existing practice, you should be suspicious that they have no clue what they are doing and view your transition as a marketing exercise only. VERY DANGEROUS! If you follow their advice and get sued, you are likely to lose, face scandal, get terminated, and be forced to transition even if the outcome of the pre-transition analysis is not to transition!

WHAT YOUR BILLING SERVICE DOESN'T KNOW CAN HURT YOU

Another physician I recently visited for their onsite consult to transition to concierge medicine in his specialty directed me to his billing service. He stated he was very happy with the gal running the billing service. So I asked her for his contracts. She didn't have them. How in heaven's name could he be happy with her if she could bill for his services and post payments without the information in the contracts? ??

• Was she using knowledge of other physician's contracts in the community? IRRELEVANT! Those aren't the rates necessarily associated with his specific contract.
• How did she know if she should write off discounts taken if he didn't even have a contract with a payer? Sometimes EOBs contain errors.
• How would she know which services are really Covered and which are not? If a remittance advice said "non-covered service, not payable" and it should be, how would she appeal and to what focal point would the appeal be sent? If a service is not paid and it should be, that's a BREACH. Where are Notices of Breach sent? Who is responsible on the health plan side to explain or rectify? In what time frame?
• He was the only doctor in his specialty using her service, so what fee schedule was she basing payments and allowables on? Another specialty or primary care?

He told me he liked her because she worked off a low percentage of collections as her fee. That's not saying much for either of them. If she doesn't bill properly or appeal properly both of them lose.

IS THE GRASS GREENER? REALLY?

Perhaps these two physicians would be happier with their current practice setting and business model and not want to jump to concierge or DPC model if their practice ran properly and efficiently in the first place.

COST TO COLLECT IN AMERICAN MEDICAL PRACTICES IS ABOUT 28% of REVENUE

But if recommend the transition and they ask me to help transition them going forward, part of the work plan and strategy has to be the run out of the billing and receivables. That cash isn't simply left to languish! Every day it becomes statistically less collectible.

If they choose DPC with no insurance, they generally terminate the biller and collector as cash is handled differently and no insurance billing is anticipated. But whoa! Who is going to collect what's on the books?

And if they choose concierge medicine with a membership fee and have their heart set on a hybrid model, part of the analysis and transition activity may be to attempt to renegotiate or obtain permission to run a hybrid model. Rarely can I make this happen but in some markets, the leverage is with the physician. If it is, I won't be able to determine this without the contract and appendix documents and attachments and the manual.

Recently, several of the primary insurers out there have written prohibitions into the contracts or administrative guides and provider manuals that FORBID continued participation if a hybrid model of concierge medicine is anticipated. Does that manual apply to all business? The commercial business only? The Medicare Advantage business?

In that case, some patients will have to be jettisoned. Where will they go? Are there other practices ready to fit them in in the community? Do you care? Let me ask you this way: What will be the revenue impact and service mix if you jettison those patients? With the reports I've requested I can estimate this pretty close to accurate. Without the reports, there's no way to project these estimates other than pulling the data out of "a large muscle group in my posterior anatomy."

VALUE ADDED BENEFIT OF A CONCIERGE OR DPC PRACTICE ASSESSMENT

I've not met with other consultants to find out what they offer when asked to transition a practice. There aren't that many out there to begin with. But one value added benefit of working with me is that my expertise is also in managed care and physician employment agreements. I've authored two internationally published books on these topics and they are relevant if you need to hire a new physician or nurse practitioner or PA, to allow you to transition to concierge and still have someone to attend to your existing traditional patient base, and to improve your existing reimbursement contracts if you decide to remain in your traditional practice.That's because in the latter case, if while I am conducting the focused review of your contracts, no matter how cursory, if I see something bad or risky for you, I say something. This is an added benefit you get when I do this analysis, but only if you have the contracts for me to review.

WHAT TO DO RIGHT NOW

1. Take an inventory of your existing in-force contracts. List them on a spreadsheet tool. List the following data elements and information highlights:

• Individual Practitioner, Group or Network (IPA, PHO, MSO, ACO, other) contract
• Starting (signing) / Effective Date
• Ending date
• Date of last fee increase or amendment of pricing
• Average percent of Medicare current fee schedule you are due
• Notice window/deadline prior to termination
• Venue and interpretation (state, county, city)
• Payment terms (timely payment rules and conditions)
• Active treatment patient protection post termination (60 days / 90 days / unstated)
• Reference to provider manual updates and changes (amendment, notice, newsletters, entire agreement provision)
• Dispute resolution method and venue and rules (mediation / arbitration / litigation; AAA or AHLA rules, single arbiter or panel of 3?)
• Complete fee schedule for all codes you bill fully-loaded in billing software program? (Y/N)
• Any mention of concierge or DPC by any name or reference in the contract or the manual? (Y/N) If yes, copy paste the text right into the spreadsheet.
• Provider relations focal point / contact details (name, address, phone, email)
• Notice recipient for health plan details (name, address, phone, email)
• Number of patients in their commercial product in your practice
• Number of patients in their Medicare Advantage product in your practice
• Number of patients in their Managed Medicaid product in your practice
• Growth trends of each product by contract over the past 36 months
• Paid-to-billed ratios by product by contract over the past 36 months
• Top three zip codes by your unique patient population by patient address for each product, by plan
• Top diagnosis codes encountered most frequently in your practice for this unique population by product, by plan, by gender, by zip code

When you can enter this data into a spreadsheet you'll have a dashboard like no other of your practice as it relates to your contracted reimbursement. Use one tab per contract "brand name". Each time you add a contract, add a tab and complete the information. Periodically update the patient population data, diagnosis and procedure data and update fee schedules accordingly when changes occur.

I will also create such a spreadsheet for you in AirTable if you like so that it is a database rather than a flat file spreadsheet. I do this as part of a contracts review I offer to medical practices, ASCs, Hospitals and other providers. I charge my usual and customary hourly rate for contract review and recommendations. Most providers have me review their top 5-7 contracts and provide feedback. Then, with the access to the AirTable database, their staff completes the remaining information on the other contracts they signed that have less impact to the practice or facility or business. They then only send me problems with complex appeals for denied claims, and they send me any updates, notices, or amendments to the fees or policies and procedures as they get them. Essentially, me and my staff become their "managed care department" on a contracted basis.

Access to this timely and accurate data can be used to inform marketing strategy, brand messaging, rebranding, and ultimately help me analyze, when added to other data I have access to, the information I need to project with reasonable expert certainty "if" you should transition to concierge or DPC business models and how long it might take to grow the practice to the size you need or want. Otherwise, it can give you a great tool to use for staffing, technology additions, use of space, scope of service expansions, workflow and patient flow planning, and other things besides the obvious: revenue management.

Don't delay. Get your contracts in order ASAP.