Posts Tagged payer contracting

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The New Age of Managed Care Contracting: Talking with Maria Todd of The Healthcare Business Institute

Managed Care Contracting

 

 

Dr. Maria Todd has been in healthcare since 1979 and has been the nation’s leading managed care trainer and consultant since 1989. She’s trained more than 70,000 healthcare professionals via more than 2500 road show seminars presented through McGraw Hill Healthcare Education Group, HFMA, MGMA, Heritage Professional Education and Business Network. Her iconic Managed Care Contracting Handbook sold more copies than any other managed care professional handbook in history, and is now in 2nd edition. No other industry professional has contributed more to the art of managed care contracting and managed care professional skills education than Dr. Todd. Manage My Practice recently sat down with her to learn more about “the new age of contracting.”

Mary Pat: Maria, you are teaching attendees at your contracting course what is new about payer contracting. What’s different in the current environment?

Maria: The managed care contracting scene is radically different under healthcare reform and the PPACA. Anyone who hasnt revisited their contracts in the past few years because they conveniently rolled overyear to year may find that they could be shut out of renegotiation, certain networks and other strategic updating that should have been done vigilantly since 2009.

Mary Pat: Do managers still need all the previous skills related to contracting with payers?

Maria: They need even more! For example, they will need to be able to safely configure bundled case rates without overlooking costly inclusions due to vague or ambiguous descriptions and accurately calculate the business opportunities and risks under capitated models.

Mary Pat: Contracting carries a lot of risk. How do you teach people about contract risk?

Maria: By showing them the ambiguities in every day contract language that doesnt look like legalese but can create loopholes for payment bundling, denials, foreclose appeals, and force the physician to refrain from billing.

Mary Pat: Many physicians have told me that there is no real negotiability in payer contracts anymore. I don’t believe that is true – what do you think?

Maria: I have always been able to negotiate some changes, perhaps not all that Id like to. The fact of the matter is that if there is nothing to negotiate, the contract is considered adhesiveand unfair and the courts can toss it out. Language can also be construed in interpretation against the drafter, if it is ambiguous. Also, the courts are not there to be paternalistic. If you negotiate some and leave others the courts put the onus on the physician or his/her manager for not finishing the job. You are not entitled to a fair contract unless you negotiate one. The class teaches participants how to spot problems and mitigate them, and provides more insight to defend a reason to say no thanks, Ive had enough!

Mary Pat: You say “Price is not the driver anymore.” What is?

Maria: New trends in contracting level the pricing field. That means that quality and service accountability, as well as adherence to evidence-based care protocols and guidelines will be measured, prescribing habits and patient engagementonly now, they will be contracted performance elements. The whole new ball game of pay for performance is now driven on different metrics. If one doesnt perform at a base level, one will have to find another ball field.

Mary Pat: Do managers and physicians need the help or review of a lawyer before they sign a payer contract?

Maria: Yes.. but for the right reasons. Too many attorneys are asked to assist on operational reviews. For most attorneys, those without practical experience in health administration and operations, (late entrants into law school after a career in healthcare, for example) the doctors and managers you mention are asking the attorneys to work outside their scope. Attorneys should, for the most part, review for enforceability and compliance, not fee schedules, operational practicability, and procedural matters that are purely at the discretion of the contracting parties to agree.

Mary Pat: In your course you discuss contracting with ACOs. Can you talk about what practices will need to learn to be able to contract appropriately with ACOs?

Maria: Which ones to align with, first. Second, how to get out if they make a bad decision, and third, what to look for and watch out for along the way. No one wants to miss the ACO with the successful management and operations and shared savings outcomes, and be left with the ACO that doesnt function well, isnt aligned and doesnt make any shared savings bonus at the end of the year.

Mary Pat: Many managers do not know how to handle ERISA (self-funded insurance plans where the employer acts as its own payer) claims. Do you teach skills to deal with ERISA claims?

Maria: I teach 3 ways to deal effectively with this problem. We know practices hear Were ERISA and we dont have to pay timely or accurately.We teach practices how to get paid faster and more accurately from ERISA payers and teach them exactly what to say to the “ERISA Excuse.”

Mary Pat: Do you talk about out-of-network strategies in your course?

Maria: Yes, because there will be times when the right strategy is to say no. Even them physicians and other healthcare providers may be able to attract market share in other ways, some that may even cost less in overhead and hassle factor – like, cash, for instance.

Mary Pat: What is the single most important thing (without giving away any trade secrets from your course!) that you wish managers and physicians would know about contracting?

Maria: How 150 words and phrases we use in everyday language like shalland other words like appropriate, adequate, reasonable, material, use best efforts, use reasonable commercial efforts, best, other, indemnify and hold harmless, can make life so miserable for physicians and their managers and collections staff because they didnt realize the implications.

Maria K. Todd, PhD

Maria has very graciously agreed to give Manage My Practice readers a 20% discount (code MMP2013) on her 3-day managed care contracting workshop which will be offered on August 14, 15 & 16, in Denver, Colorado. The Healthcare Business Institute, a new non-profit training and professional skills development institute in Denver, Colorado will host this hands-on workshop at the Grand Hyatt Denver Downtown. For more information and registration, call 800-209-7263 or register online here.

(Photo Credit: photos by blperk via Compfight cc)

Posted in: Compliance, Day-to-Day Operations, Finance

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The Complete Guide to Revenue Cycle Management – A New Comprehensive Course from Manage My Practice

You spoke and we listened – you asked for a comprehensive course on Revenue Cycle Management and we brought it to you!

This series is for anyone who wants to understand the medical practice revenue cycle from the very beginning to the very end: physicians, physician assistants, nurse practitioners, advanced practice registered nurses, practice administrators, office managers, consultants, vendors, students, coders, billers and those who want a RCM foundation to enter the healthcare field. Anyone who wants to know more about how reimbursement in healthcare works in the medical practice will find this comprehensive series indispensable.

You won’t find this comprehensive course anywhere else except at Manage My Practice. Webinar leader Mary Pat Whaley, FACMPE, CPC has developed this program from 25+ years of experience in medical practice management and from requests she gets weekly for education on the revenue cycle management process.

Improve Your Medical Practice's Revenue Cycle

The Complete Guide to Revenue Cycle Management – a Five Module Comprehensive Curriculum

Module I. The Foundation

  • Payer Contracting
  • Credentialing
  • Payer Matrix
  • Setting a Fee Schedule
  • Understanding Medicare Part B

Module II. The Data Build

  • Practice Management System Set-up
  • Allowables
  • Patient Demographics & Insurance Information
  • Eligibility & Benefits
  • CPTs, HCPCS, ICD-9

Module III. The Pre-Claim Process

  • Collecting at TOS
  • Documentation: Paper vs Electronic Medical Records (EMR)
  • Physician Coding vs. Abstraction Coding
  • The Superbill vs. Using the EMR to Bill
  • Claim Scrubbing: The Three Gates

Module IV. The Post-Claim Process

  • Write-offs, Denials and Appeals
  • Daily Reconciliation Process
  • Patient Collections and Payment Plans
  • Refunds
  • Recoupments

Module V. Monitoring

  • Monthly Reports
  • The Practice Dashboard/Snapshot Report
  • Strategies for Improving Revenue
  • Benchmarks for Staffing
  • Revenue Cycle Compliance and Auditing

Also Included! Action Pack – Handouts in Word/Excel

  1. Contract Reference Matrix
  2. Contract Review Template
  3. Fee Schedule Worksheet
  4. Medicare Resources
  5. Allowable Cheat Sheet
  6. Write-off Approval Form
  7. Daily Reconciliation Form
  8. Refund Request
  9. Monthly Report List
  10. Sample Snapshot Report
  11. Sample Revenue Cycle Compliance Plan

 

Here’s what one attendee wrote about a recent Manage My Practice Webinar “Information was right on! Great examples and real life experiences.”

 

5-Week Course for $799.00 (Two Options)

Option One : Every Tuesday for Five Weeks – March 12, 19, 26, April 2, and April 9

Click Here To Register!

Module I: Tuesday, March 12 @7pm ET for 90 minutes

Module II: Tuesday, March 19 @7pm ET for 90 minutes

Module III: Tuesday, March 26 @7pm ET for 90 minutes

Module IV: Tuesday, April 2 @7pm ET for 90 minutes

Module V: Tuesday, April 9 @7pm ET for 90 minutes

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Option Two: Every Thursday for Five Weeks – March 14, 21, 28, April 4 and April 11

Click Here To Register!

Module I: Thursday, March 14 @1pm ET for 90 minutes

Module II: Thursday, March 21 @1pm ET for 90 minutes

Module III: Thursday, March 28 @1pm ET for 90 minutes

Module IV: Thursday, April 4 @1pm ET for 90 minutes

Module V: Thursday, April 11 @1pm ET for 90 minutes

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Mary Pat Whaley

Mary Pat Whaley, FACMPE, CPC has 25+ years managing physician practices of all sizes and specialties in the private and public sectors. She is Certified Professional Coder, is Board Certified in Medical Practice Management and is a Fellow in the American College of Medical Practice Executives. Mary Pat has been providing free information and resources to physicians, care providers and medical practice executives since 2008. For questions about “The Complete Guide to Revenue Cycle Management” webinar, contact Mary Pat at (919) 370-0504.

Posted in: A Career in Practice Management, Collections, Billing & Coding, Compliance, Day-to-Day Operations, Finance, Medical Coding Education, Medicare & Reimbursement

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