How To Get Contracted into t Closed / Narrow Networks The Secret Sauce. Presented by: Steve Selbst CEO / Co Owner, Healthcents, Inc.

Transcription

1 How To Get Contracted into t Closed / Narrow Networks The Secret Sauce Presented by: Steve Selbst CEO / Co Owner, Healthcents, Inc. May, 2018

2 Healthcents Services Payer contracts analysis and negotiations Credentialing Services Marketing Services (Traditional and Online) Claims analysis / troubleshooting and payments Claims audits RevolutionSoftware, our unique cloud-based contracting software Education and training in payer contracting, BluePrint for Success (online and live) Healthcare Business Consulting Services 2

3 Leadership Mr. Steve Selbst, CEO (Leads Operations) Manages Healthcents Operations including contract negotiations Successfully negotiated 40,000+ payer contracts Invented RevolutionSoftware and designed the product Designed and delivered Blueprint for Success Payer Contracting Class 30 years as a Software and Business Executive in the Software Business at IBM BS Degree in Business Admin, Arizona State University, Summa Cum Laude, and invited to apply for a Fulbright Scholarship Ms. Susan Charkin, President (Leads Client Strategy and Sales) The Nationwide Expert in Payer Contracting and Strategy, well known President of Healthcents since years of Senior Contracting Positions for payers and providers (Healthnet, BCBS, Aetna, University of California, San Francisco, Maxicare and others) Trustee of Natividad Hospital- largest public hospital in central California, a teaching hospital affiliated with UCSF Leading Author and National Speaker on Managed Care (Boston University, George Washington University, American Ambulance Association, Specialty Capitation, Beckers ASC EMS Insider and others) Expert in ACO s, put together key roadmap for AUA, interviewed Dr. Elliott Fisher, Brookings Institute, Blue Cross of CA and an early IPA implementer Undergraduate Degree in Education (UVM) and MPH Degree (USF) 3

4 Goals & Objectives Define Closed and Narrow networks and the implications to any provider of medical products and / or services Learn how to navigate closed and narrow networks to get contracted and generate more revenue 4

5 Agenda Define Closed and Narrow networks and the implications to providers Types of Payer Contracts- which one(s) are best for you? What are payers looking for? Ask not what the payers can do for you but what you can do for the payers Learn strategies and tactics to get contracted with commercial payers who have closed or narrow networks Building effective value propositions (proposal letters) Over come obstacles Complementary Payers and IPAs Any Willing Provider Steps to getting contracted- Good payer contracting hygiene 5

6 What is a closed or narrow network? Closed-Payer has established a practice (usually not a policy) that it is not accepting more providers into a specific network type-e.g., DME / HME, since its network is full Narrow-Payer has established a practice (usually not a policy) that it is generally not accepting more providers into a specific network type-e.g., DME / HME, since its network currently has the optimal number of providers it needs 6

7 Network Types Open or Any Willing Provider : Narrow Network: Closed Network: 7

8 Why the distinction? It often is more likely that a provider with the right value proposition can get into a narrow network Providers with unique and innovative offerings may be able to break into a closed network Sometimes the two scenarios are effectively the same 8

9 Payer Contracts Types Commercial PPO, HMO Fee for service, capitated, value based Complementary (Often not considered and key!) Government o Medicare (Medicare Advantage) o Medicaid o VA Primary Leased networks Secondary leased networks IPAs, ACOs, Employer Groups 9

10 Payer Contracts Types Commercial Payers, ACOs, IPAs Primary Payer Complementary Payer Insurer / IPA Re-Pricer Complementary Primary Payer Commercial Payers, TPAs, Medi Medi, Employers, VA, IPA Complementary Secondary Payer Commercial Payers 10

11 Which contract(s) are best? Am I price sensitive? Is my product useful to Medicare and Medicaid patients? Who are the large commercial payers in the area? Use a data source if possible to identify Who are the large employer groups and which payers do they use to cover their employees? 11

12 What products and services do payers want? Based on an informal survey of large payers across the USA our findings are: New technology that is a game changer Products or services that save cost Non Par Providers with high utilization Service benefits that demonstrate better compliance and clinical outcomes Products which enable patients to move out of the hospital while awaiting surgeries Products that provide alternative treatment methods vs. surgeries and procedures Key referrals -providers and employers 12

13 Consider this... Services and / or products in a given category are all similarly reimbursed by all payers. What do you do when cost is no longer a competitive advantage? 13

14 Implications to Providers You will likely need a unique value proposition to get into a closed or narrow network Often price competitiveness coupled with value is key; can revisit after initial contract term 14

15 How to Differentiate your value First, there are no silver bullets Biggest, Best, Only Clinical Benefits leading to cost savings Product Advantages Service Advantages Geographic Coverage Referrals Out of Network Business, Book of business potential What about price? 15

16 SWOT Analysis Strength Products / Services Location Size and Market Importance Referral Network Opportunities Employer Groups New or Specialized Products and Services Value Based Contracting Service Advantages Weakness Competing Companies Payer Reimbursement Policy Threats Mergers Payer initiated ACOs Out of Network Reimbursement Policy 16

17 Product Advantages Do you have product(s) in your portfolio or that you deploy which are unique and will save the payer money and provide treatment benefits? Product that reduces testing that eliminates biopsies An HME wearable device that reduces ulcers and saves limbs A remote monitor that enables patient s awaiting organ transplants to go outpatient A Davinci Robot for prostate surgery 17

18 Service Advantages Who are the key stakeholders in your referral network? Do you cover geographies that your competition doesn t? Do you serve rural and underserved communities? Do you provide 24x7 service (Medical Products Companies)? Is your order response time or service much faster or better than competition? Do you have specialists or therapists that do custom fits and provide custom one on one customer service? Are they in all key locations? (Medical Products Companies) Can you demonstrate better clinical outcomes including surgery avoidance and down stream complications? 18

19 Treatment Advantages Does your product or service eliminate inpatient stay days at a hospital? Does your product or service reduce the need for invasive surgeries? Does your product enable alternative treatment to invasive surgeries? Does your product improve patient health in a way that reduces payers costs? 19

20 Example time Now let s look at an example that focuses on service efficiency, as a template, that you can use and modify based on your specific value proposition! This example assumes that the provider has submitted a request for participation but was told the network is closed. 20

21 Opening Establish your relationship with the payer - State the reason for contact and establish Company / Practice relationship with plan. Below is an example of an opening paragraph: I am contacting you on behalf of Company or Practice NAME to initiate a renegotiation of their current fee schedule. The Practice is focused on value and quality, and routinely performs surgical services in the office setting, when medically appropriate. Additionally, they utilize in-network outpatient surgical centers and work diligently to refer patients to in-network ancillary providers for services outside the office setting. Company or Practice has been a Par provider in your network since YEAR. For commercial business, in the past 12 months, the practice provided care to #### PAYER covered lives, receiving $$$ for rendered services from PAYER. 21

22 In the letter body Incorporate what makes your practice / company a good partner. Highlight service area, specialties, unique services, clinical and administrative efficiency that makes your practice a good partner in the payer network. Company / Practice is the only Company / Practice in area (specify if possible, e.g. city, county, state ) that provides SPECIAL PROCEDURES. Practice also provides extensive unique office based procedures. Their professional specialties include LIST SUB OR SPECIFIC SPECIALTIES. The effect of handling these procedures in our office vs. the local hospital is an estimated savings of $$$ to PAYER s commercial network. 22

23 The close Close the sale. Restate the purpose of the letter and throw the hook : COMPANY / PRACTICE remains committed to continuing to working with you and caring for your members. Attached to this letter is a proposal that is commensurate with the value that they bring to your network and to your members. I am confident that we can reach an agreement on a mutually acceptable fee schedule. Your written reply to this proposal is requested by no later than DATE. In the meantime, if you have any questions about the practice or the attached proposal, please do not hesitate to contact me. 23

24 Overcoming Obstacles Value Proposition First: Focus on a combination of pricing / value, restate when escalating due to a no Complementary Payers (Primary and Secondary leased networks) Complementary Payers such as IPAs, VA, Medi Medi Plans Any Willing Provider LOAs 24

25 Best Practices for Payer Contracting Data Analysis Proposal Letter Make Initial Contact with Payer Negotiate until agreement is reached Analyze Counter offers Escalate to Senior Management Consider Out of Network Option Monitor Claims Re-Negotiate Phase 1: Prepare Phase 2: Negotiate Phase 2: Continue to Negotiate Phase 3: Monitor / Re-negotiate Negotiations Completed 25

26 PREPARE: 10 Best Contracting Practices Best Practice 1: Evaluate top codes and figure out which ones are driving revenue. Best Practice 2: Benchmark against Medicare and other payers with which you have contracts to identify areas where you may be under reimbursed compared to the market. Use the 20/80 rule. Best Practice 3: SWOT Analysis for your payer fee schedules: Look for opportunities to increase reimbursement for services that are not reimbursed at market competitive rates, and assess your chargemaster. Best Practice 4: SWOT Analysis for your practice. Best Practice 5: Prepare an impactful proposal letter. 26

27 NEGOTIATE: 10 Best Contracting Practices Best Practice 6: Deliver your proposal letter to the appropriate network manager, do initial follow up and establish rapport. Best Practice 7: Follow up frequently and keep the payer representative engaged. Respond quickly to any requests they make for additional information and to any proposals you receive from the payer. Best Practice 8: Evaluate payer proposals and look for ways to optimize counter offers. Don t take first No as an answer, and use escalation to Sr. Management judiciously. Best Practice 9: Review contract for language that affects reimbursement. MONITOR: Best Practice 10: Monitor payments, identify reimbursement issues quickly and work closely with your payer representatives to resolve any payment issues as quickly as possible. 27

28 Summary Defineyour competitive advantage Identifyyour payer contactand work with them Leverage: Yourexistingemployer and referral relationships Be persistent! 28

29 Questions? Contact the speaker at: or or To obtain a copy of the slides of this presentation go to: Our full suite of services include: Payer contracting analysis and negotiations o Including letters of agreement, claims trouble shooting, and claims payment verification Online Marketing Outreach RevolutionSoftware, our unique cloud-based contracting software Education and training in payer contracting Consulting packages customized for your needs Led by a team with decades of healthcare and technology expertise, Healthcents is the go-to authority for organizations such as the American Urological Association and Quill Healthcare (a division of Staples) We have presented at two Medtrade sessions More information at info@healthcents.com or