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Navigating the Pitfalls of Payer Provider Contracting


This white paper originated from a simple question regarding lower reimbursements due to increased write-offs from eligibility related denials.  Are other’s seeing a pattern of denials for credentialing and/or out of network adjudication due to the complexity of plans and product lines that leave the provider unable to confirm whether they should see a patient at the point of treatment or not?

Know Your Contracts
It’s no longer enough for providers to know that they are contracted with a health plan. With the Affordable Care Act payers have several product lines tailored to various consumer needs.  

Understanding the Payer Product Line landscape

  • Platinum, Gold, Silver, Bronze and combinations thereof to fit healthcare needs and budgets.
  • Narrow Networks having exclusivity based on geography, patient volume, and healthcare needs.
  • Insurance brokers and healthcare population management networks.
  • Are you eligible to participate in certain product lines?
  • Do you choose to participate in certain product lines?
  • What’s hidden in the fine print of the contract? Are you getting what you chose?

Review and Manage Contracts in this New Reality.

  • Re-negotiate existing contracts where possible
  • Maintain your auto renewal date of your existing contracts and flag them for review 90 days prior.
  • Maintain your patient volume per plan and product line (understand the patient populations. Has there been a change in where the patients are going?).
  • Adding new product lines where desirable.
  • Terminate the undesirable product lines.

Educate Registration Staff at the Point of Treatment

  • Train the registration staff what to look for when the patient presents an insurance card.
    • Verify the provider is in-network with specific product line/service.  
    • Understand the deductible for each and every patient encounter and explain this to the patient prior to engagement.
    • Verify benefits and note the terms of coverage.
    • Understand the need for pre-authorization if necessary and collect correct co-pay based on product line.
  • Continually re-train and reinforce as changes occur related to each payer product line.

Third Party Billing Companies Added Value
Today many providers and third party billing companies farm out the credentialing function.  It is becoming increasingly evident that there is a gap in understanding at the point of treatment.  This increased lack of understanding is resulting in delay in payment to the provider and increased complexity of the need for appeals after patient to provider engagement.  The end result is lower allowable amounts to the provider and higher deductible amounts to the patient, decreasing patient satisfaction.

Third party billing companies can maintain a contract matrix as well as contract termination dates for their clients.  Billing companies can incorporate the role of educating the provider and his/her practice team managing their patient intake effectively.  

Due to the complexity of payer to provider contracting it may be best to review your managed care contracts and decide if a better solution is to incorporate this into your billing service agreement with the provider.  This would potentially increase the partnership approach with the provider and increase reimbursements to all parties involved.  

Below are some key concepts to remember when reviewing a contract.

The fine print in each contract needs to be reviewed to confirm:

  • Terms
  • Rate - Fixed or Rolling?
  • Termination Date
  • Carve-Outs
  • Provider Specialty Terms
  • CPT and DX code Exclusions
  • Bundled Payments
  • Fee Schedule Changes
  • Provider Enrollment Guidelines
  • Product Lines
  • Authorization Needs
  • Referral Guidelines


In Conclusion
You can no longer put your contacts on a shelf and forget about them.  Today we are dealing with complex contract negotiations.  Gone are the days of dealing with a PPO payer contract, it is now a PPO, HMO, POS, Medicare Replacement, Medicaid Replacement, ACO contract all in one.  In addition, the rules are ever changing regarding authorization and engagement with PCPs or specialists.  We are moving away from the day to day billing with our providers and engaging more at a high level as it relates to contract management. 


Authored By:
Veena Mahendru
HBMA, Commercial Payer Relations Committee Member