Experience. Integrity. Advocacy.
Experience. Integrity. Advocacy.

Navigating Payer Contracts

While the debate over out-of-network balance billing rages on, one way to minimize the impact would be to enter into and maintain contracts with payers. Of course that doesn’t make the issue go away completely; physicians will always remain outwork with some payers. Also, many practices would like to participate in more payer networks, but they remain out-of-network because payers refuse to offer reasonable rates for services.

For those payers that you do decide to go or remain in-network with, here are a few tips for navigating payer contracts for maximum reimbursement.

Know Your Contracts

Do you know which payers and networks you currently contract with? What about which product lines for the Exchange plans? Are you in network with any narrow networks? If so, are you taking advantage of referral opportunities by reaching out to primary care physicians? Finally, what are the terms of those contracts, and do they still meet your current practice needs?

The first step to navigating payer contracts is to keep an updated list of all contracted payers and product lines and to understand the terms of each, especially negotiated payment rates.

Know Your Payer Mix

Do you know which out-of-network payers are represented by your patients? Are there are any large volume payers with which you might possibly be able to negotiate fair terms for in-network status? What about changes in volume with your in-network payers? Has a large employer in your area changed networks providing you with increased negotiating power?

Use business analytics to track shifts in your payer mix. Applying contracted payment rates to shifting payer mix data can help you predict changes in revenue and attempt to stave off any major drops through renegotiating contracts.

Know Your Payer Performance

Do you know which in-network payers maintain the highest average payments per encounter? Also, which payers have the highest no-pay rate among their members? What about denials and appeals? Which payers pay correctly the first time and which payers require a lot of follow up?

Holding payers accountable to the contract terms you’ve already agreed to is important for maximizing your in-network status. Compare actual payments with negotiated rates to be sure payers are not underpaying for your services. Also, with rising deductibles, many patients—even insured patients—end up making no payments or having no payments made on their behalf for medical visits and encounters, especially early in the year after deductibles are reset. In your contract negotiations, use blind comparison reports to show payers the differences between theirs and their competitors’ denial, payment, and no-pay performance rates.

Know Your Dates

Do you know when contracts are set to renew or expire or when new contracted fee schedules go into effect? Do you know when you should begin renegotiating contracts or when you last renegotiated your contracts? Do you know when provider credentials expire or need to be updated?

Keeping track of all the dates and deadlines of managed care contracts is a tedious process. But staying on top of all the renewals and deadlines will help you effectively renegotiate new contracts and apply changing payment rates in a timely and efficient manner.

Know the Details

According to our friends at the Healthcare Business Management Association (HBMA), managing payer contracts has become so complex that many companies are choosing to outsource that function to their medical billing company or other consultants. CIPROMS offers many resources to help practices manage payer contracts, including business analytics to track in-network and out-of-network payer performance data, referrals to professional provider advocates for contract renegotiations, plus comprehensive provider enrollment and credentialing as both a stand-alone service and as part of our full-service medical billing.

Whether you are handling your payer contracts on your own or outsourcing some of the work, HBMA recommends reviewing the following items with every contract:

  • 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

Don’t let your payer contracts become outdated from neglect. Pull them off the shelf, roll up your sleeves, and get to work making your contracts work for you and your practice.

— All rights reserved. For use or reprint in your blog, website, or publication, please contact us at cipromsmarketing@ciproms.com.


Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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