It may feel like your practice is fighting a losing battle with reimbursement. After all, continual rate declines amidst increasing overhead and regulatory burdens are enough to dishearten even the most optimistic physicians and administrators.
Many changes are occurring on the reimbursement front however, and though change can be uncomfortable, it can also bring new opportunities. For your practice, that means the difference between a cloudy forecast and a bright one could come down to whether you are prepared to successfully take advantage of the changes.
Here are five ways your practice can make the most of its current payer contracts and capitalize on the changing reimbursement environmen
MONITOR CONTRACT CHANGES
As the healthcare landscape shifts due to health reform, more payers are modifying their contracts with practices — and managers need to pay attention. The more informed you are about upcoming contract changes, such as a payment adjustment or a move to a different Medicare base year, the more prepared you will be to deal with them. In addition, you will have more time to attempt to fight changes, if necessary, before they go into effect.
Keep in mind that payers can sometimes add amendments to contracts without requiring your signature, so it’s even more critical to closely monitor any notifications you receive. If you receive mail from a payer, read it and reread it and call to ask questions until you fully understand the ramification is for you.
Lastly, keep a close eye on your explanation of benefits statements and your electronic remittance advice reports. Avoid assuming something went to the deductible. Make sure and actually follow up with the payer and find out if something has fundamentally changed.
CONDUCT A CONTRACT CHECK UP
In addition to watching out for contract changes, review all of your payer contracts at least annually to ensure that the terms still work for your practice. You may have added a new service recently that wasn’t included in the original contract, or the cost of a service may have suddenly skyrocketed and the payment you are receiving no longer matches up. When you do come across these issues, reach out to your payer and try to work out a suitable solution.
Double check the accuracy of your payments regularly. That way if a payer makes a mistake or if a system glitch negatively affects your payments, you can rectify the issue as quickly as possible.
PAY ATTENTION TO EXCHANGES
When assessing your payer contracts, consider how plans purchased through the health insurance exchanges could affect your reimbursement. Whether you want to participate in an exchange plan, also consider the high deductibles included in many offerings, as that could slow your practice down. Consider the time your staff members will spend attempting to collect patient payments and educating them about how their plan works.
If your practice has been included in an exchange plan and it wants to be removed from the plan, review your contract with that payer as soon as possible. You might be able to opt out of the plan at your contract anniversary or renewal date.
UNDERSTAND VALUE
The shift toward value-based payment, in which payers provide higher reimbursement to practices that meet quality and cost targets, is another area to watch.
While the extent of the shift to value-based reimbursement varies throughout the country — it’s occurring much more slowly in small, rural communities — all practices should be preparing.
Proactively approaching value-based payment can also help you prepare for Medicare’s value-based payment modifier. The modifier will tie Medicare payments to quality and cost performance. This year, in 2017, the modifier will kick in for most physicians, and it will be based on their quality reporting and performance this year.
FIND NEW NEGOTIATING LEVERAGE
A proactive approach to value may also help you succeed in payer negotiations. If you can prove to payers that you are providing high quality, low-cost care, they may be more willing to offer higher reimbursement rates or incentives. Here are a few ways to prove to payers that your practice is taking value seriously:
• Establish a quality improvement program with a designated physician and staff leader.
• Identify gaps in your quality performance, such as reviewing performance data provided by payers. Then, work to improve in those areas.
• Look at the most common quality and cost metrics the payers in your market are using. Then, measure your practice against those metrics.
• Ensure that your physicians are consistently following evidence-based or clinical treatment guidelines.
• Pursue recognition as a Patient-Centered Medical Home or a Patient-Centered Specialty Practice, as more payers are offering related reimbursement increases or monthly care coordination payments.
• Implement a patient satisfaction improvement program by surveying patients regularly and working to improve performance.
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