Opening Lines of Communication with Payers

One of the most effective steps organizations can take when negotiating managed care contracts is to advance transparent communication with payers. For physicians and managed care executives, the challenge lies in conveying the capital-intensive nature of their services.

Demonstrating a willingness to engage in open and honest communication will enhance physicians' credibility and reputation. This will lead to more respectful and serious consideration of your proposals by insurance executives.

Setting the Stage

This unique strategy comes against the backdrop of macro-economic pressures forcing providers to look beyond cost structure and operations to ensure financial growth.

The Changing Role of National Health Plans in Many Markets

Big national healthcare companies have been in a growth mode that emphasizes vertical integration. If your objective is to instill resilience into your organization, you want to avoid tying too much of your performance to one plan that also may be competing with you in certain service areas.

Considering Payer Partnerships

As healthcare organizations consider partnering with payers, providers and practice administrators should consider these questions:

• Would a partnership enable or limit our resilience in the market?
• Does the partnership move us closer to the premium dollar?
• Does it enable us to capture a fair share of the value we are creating?
• Does it enable us to grow more proximate to patients?
• Will we be able to deliver a differentiated experience to patients?

The Rapid Evolution of Today’s Healthcare Marketplace

In the past, physicians and managed care executives might have assumed their organization’s payer mix would always be constant over their career, but the reality is that both are changing very rapidly in a lot of markets.

There’s a shrinking commercial base and a growth on the government side particularly with Medicare Advantage (MA) plans and Medicaid. There’s also a whole Medicaid redetermination process that’s occurring. This changes the mix of the members and patients that organizations serve and has serious economic implications for every healthcare company.

What’s the Solution? Collaboration

Healthier conversations and negotiations occur when everyone comes together with an open mind and an agreement on the fact that healthcare today is too expensive. The market demands more affordable solutions and products. The best way to deliver that is to work together and not against each other.

Regardless of structure, goals of the relationship should include:

• Delivering integrated care and coverage options that combine plan and provider
• Partnering to reduce total cost of care on a per member and population basis
• Structuring the relationship to reward desired performance and outcomes
• Partnering with a regional plan to build a Medicare Advantage (MA) product to counter the strength of certain national payers in the MA market

The Reality Is That Plans Need Providers

That can be seen in terms of what activities payers are pursuing, how they’re vertically integrating with different parts of the provider universe and even acquiring provider assets.

Providers also need plans. They need to understand the total cost of care and the health status of the population they’re serving. They need this information on a real-time basis to make the right decisions and change behaviors.

Summary

Early discussions will help clarify what each party expects from the negotiation. This will prevent misunderstandings and ensure that both parties are on the same page regarding key issues such as reimbursement rates, coverage policies, and administrative processes.

By communicating early, physicians can identify areas of agreement and common interests. This will serve as a foundation for building a more comprehensive agreement and will make it easier to resolve more contentious issues.

Early communication will also facilitate joint problem-solving and the development of creative solutions that might not emerge in a more adversarial negotiation setting.

The Physician's Advocate In Payer Contracting

One must recognize that payer contract management and negotiation is an ongoing process, not a one-time event.

CodeToolz eliminates the need to the add permanent overhead costs of hiring and maintaining a full-time staff of contract negotiators, managed care analysts, and contract managers to your practice. Our team will perform all of these functions.

Our achievements have been acknowledged throughout the healthcare industry. Learn from various organizations and healthcare providers about the significant improvements we made to their practice revenue, and discover how we can specifically assist you in achieving similar results. Testimonials

Contact Us Today (512) 787-1852 or Schedule Your Free Consultation / Demo here.