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By WCH Chief Operating Officer Olga Khabinskay

When I started working in healthcare 16 years ago, generous fee schedules kept American medical practices profitable. However, changes over the past seven years have made contract management more complicated. Insurance companies often cut fee schedules by as much as two-three percent a year, and merely toss doctors out of their network when they aren’t willing to negotiate. 

For the most part, insurance companies only offer new rates to new providers. So, a doctor who signed a contract 20 years ago may continue to get 20-year-old rates while newer providers benefit from better rates. Many physicians don’t realize they can revisit their contract, review rates, and ask for changes in their fee schedule years after they sign with an insurance company.

Periodically reviewing insurance contracts and renegotiating rates can bring more money into certain practices—especially those that provide unique or much-needed services in high demand areas. A billing company can help analyze contracts and navigate negotiations to optimize revenue in several ways.

First, a biller with extensive experience in a particular  area can do a preliminary review to determine where a provider is losing reimbursement revenue. A more comprehensive examination can indicate whether it makes more sense to leave an insurance company, reassign patients to another plan or request a contract renegotiation.

The next step is to analyze current revenue and  compare it to other practices with the same specialty in the same area. Typically, doctors who enroll at the same time get the same rates. If you notice that similar practices, who signed their contracts with the same insurance carrier several years apart, are getting significantly different reimbursements, you can work with an experienced advocate to help renegotiate for better, more current fees and rates. Insurance companies are more likely to negotiate with providers who:
Serve a large percentage of their in-network patients. If there are 20 primary care providers in a two-block radius, an insurer will be more likely to continue working with a more heavily utilized practice and let an underperforming one go.
Provide a unique service in a strategically-beneficial location.  For example, the only pediatric endocrinologist within 10 miles can negotiate a better rate for treating patients who would otherwise seek treatment at a more expensive hospital. 
Target specific procedures or tests. Focus on where you might be most likely to be successful by requesting a small percent increase only for the most commonly performed or expensive 
procedures. These include anesthesiology, X-rays, CTs, or other specific diagnostics.

Navigating the Negotiation Process

A quality billing company establishes strong working relationships with dedicated insurance representatives who ultimately grant negotiation requests based on overall practice performance. They weigh several factors, including: how much providers bill to insurance; how much they receive; clean claim rates; and the number of audits passed or failed. 

The reps will either accept or decline a practice’s request based  on perceived value to their network. An insurer will want to know why patients use the practice and why they should continue working with the practice under a newly-negotiated contract. It is also important to include pertinent clinical  information from a physician or director. 

A negotiation request should include information about:
• Measures that help keep patient populations healthier
• Procedures that save lives or cut down on hospital admissions
• Expanded office hours that improve access for members
• Practice staff, including physicians, registered nurses, physician’s assistants, etc.
• Facility size and operating expenses - for example, working longer hours incurs overtime costs
• Flat rate services - an urgent care center that gets a flat rate for all visits can request additional reimbursement for expensive CAT scans, MRIs or X-ray

Bottom Line Benefit

Clearly, providers are so focused on patient care and the administration that changing an insurance agreement seems like an added headache. However, practices may be leaving many thousands of dollars on the table if they do not know where to look and are not embracing the need to re-negotiate. 

WCH Service Bureau is the #1 billing and credentialing company in the tri-state, New York area.

September 2019