Contract Management & Payer Negotiations
At PayrAdvisors, we bring a whole suite of services tailored to the success of your business. Outside of negotiating a better rate, contract management is one of the most vital operations that will determine the success of your practice. Many practices lose track over time of who is credentialed to what contracts, what contracts apply to what locations and what terms / requirements are within each agreement. We track agreements, provider notices, credentialing requirements, fee schedules and all other documents that pertain to the financial well being of your payer agreements.
The heart of what we do. We have been negotiating payer contracts in all 50 states for all services lines from small physician groups to large academic health systems. We ONLY work for provider group organizations – we are YOUR advocate for better reimbursement. With the rising costs of operations, regulatory compliance and provider obligations – managing a practice in today’s world is a daunting challenge. With the right team to negotiate on your behalf, you can drive your practice to the next level by maintaining independence and competing in your marketplace. Unlike other management consulting firms, we fight & we fight hard for you. We work with you to develop a strategy tailored to the wants and needs of your practice – and we execute. We work alongside you from beginning to end and communicate in a regular cadence to keep you apprised of the progress.
The 6 Key Factors Determining Ability to Negotiate Include:
Decision Makers
One of the most critical steps in the ability to negotiate a payer contract is working directly with the individuals at the health plan who have P&L responsibility. Many providers can never get past the gatekeepers of “Provider representative” who have no authority to negotiate contracts and only offer the standard reimbursement contracts which oftentimes is far below market rates.
This is where we come in. We work with the market leaders at health plans to negotiate your contracts. It is imperative to work directly with the payer contracting team who understand your scope of services, your market share and value to ensure you receive bench market reimbursement.
Market Share
How many providers of your specialty are in your market? Knowing who you compete against in a given market is a must to understand how much leverage you do or do not have in a negotiation.
Economic Competitiveness
Are you the cheapest option in your area? Oftentimes a competitive edge is being the cheaper option – meaning payers need you in their network and will oftentimes offer increases to keep you in their network at a lower rate than large competitors.
Established or New?
New providers who are out-of-network wishing to go in-network typically have the lowest leverage unless they satisfy components a or b. For example, many infusion centers enter markets and can negotiate good rates from the beginning because they are a cheaper entrant into the market vs. hospital outpatient infusion departments.
Existing providers with significant patients on panel > 1000 patients have considerable leverage in re-negotiating agreements – this should be completed every single year when outside the initial term of the agreement.
Understanding Market Limitations
Existing providers oftentimes have significantly outdated payer contracts with rates yielding reimbursement below current Medicare (depending on specialty). Moving to a market rate may take 2-3 years as payers have to budget and adjust premiums in the current year to account for budget requirements.
There are numerous data vendors such as FairHealth & Truven that source current market and payment rates by physician type, locality, CPT code, payer & product type etc. that serve as a guidance metric for practices to achieve rate parity.
Exceptional Clinical Quality
Many of our clients perform exceptional clinical care which is an important piece for us to relay to the health plan when asking for premium rates. Being a high quality provider who offers services above and beyond the typical medical group – saves payers money.
Clinical trials, quality outcomes and patient satisfaction are key drivers in the ability to garner better contracts. We advocate for you and we are your voice in this process. We often broker meetings between the clinical group leadership and the Chief Medical Officer at the health plan to ensure the physician to physician component echoes the sentiment of your contracting consultants.
Contact Us Now to better understand the expectations and timing as it relates to the complex process of managed care negotiations.