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Comments on “Negotiating in a Managed Care World”
COMMENTARY
Comments on “Negotiating in a Managed Care World” Brian J. McKee, MBA, Robert L. Siegle, MD, MPA “Negotiating in a Managed Care World” provides a broad range of excellent advice. We have a few additional items that you might want to consider for the negotiating process. These fall into the category of lessons learned. CREDENTIALING Provider credentialing means more than just adhering to the insurer’s rules about what makes a physician acceptable as a provider. It means dealing with the delays built into the process, some unavoidable and some willful. Always negotiate for the shortest possible response time from the managed care company. Aim for 60 days from start to finish. Even if you follow the process diligently and completely, the companies may take months to assign provider numbers. This issue can be addressed in several ways. Make sure the requisite materials are complete and up to date when they are provided to the managed care companies, so that the insurer does not have an opportunity to return the documents and delay the process. Delay the new radiologist’s start date until some or all of the provider numbers have been assigned by the group’s primary payers. In the current recruiting environment, this approach works best when you have a long lead time to employment, such as recruiting from residency or fellowship programs. As part of the recruiting process, make sure that you assist residents or fellows with applications for their full unrestricted medical licenses and DEA numbers, when850
ever appropriate, while still in training. Both of these may be required documents in the managed care credentialing process. Alternatively, it may be possible to negotiate standards with the payers. Such standards could include reimbursement for services rendered before that provider number is issued, especially if there are unreasonable delays in obtaining the provider number. Another option would be to negotiate with the managed care company to pay for inpatient hospital services regardless of the participation status or alternatively to bill using a participating group number rather than waiting for an individual provider number. A possibility for large physician groups is negotiating delegated credentialing. Delegated credentialing transfers the responsibility for credentialing from the managed care plan to the provider group. The group must demonstrate the ability to take on the credentialing functions the plan would normally perform. In exchange for taking on this process, the group is able to have physicians credentialed on, or very close, to their start dates. As a last resort, you might consider assigning the newest radiologist employee responsibility for reading the lowest reimbursed modality as often as possible to minimize revenue loss until provider numbers are obtained. CLEAN CLAIMS AND TIMELY FILING The insurer’s failure to meet any “clean claim” limits should include
interest on delayed payments. Check out your state’s prompt-pay laws and understand how interest is paid, because this might add up to significant dollars on high-ticket items that are not paid in a timely manner. All of your managed care contracts will have timely filing clauses. In contrast to what the authors state, our experience shows that managed care companies will have a single timely filing limit for both inpatient and outpatient services. Negotiating 180 days for timely filing is preferable, for the initial claim submission, as well as an additional 180 days for the claim appeal process. REIMBURSEMENT ISSUES Radiology services are generally reimbursed 1 of 2 ways: fee for service, as the authors discuss, and capitation, which is a prepaid amount of money paid per member per month to the radiology group to provide certain services regardless of member use. As the authors indicate, it is very important to negotiate higher fee-for-service reimbursements for high-volume procedures. Additionally, you will want to maximize the number of high-end services that are excluded from capitated contracts. To be successful, radiologists must be aware of their historical service mix (volume by Current Procedural Terminology [CPT] code by payer) and obtain a CPT-specific listing of capitated services. There is perpetual concern about payable diagnoses for each CPT code. Each managed care company may have its own nuances for these
© 2005 American College of Radiology 0091-2182/05/$30.00 ● DOI 10.1016/j.jacr.2005.04.002
Commentary 851
things, and they are probably averse to sharing them with you. But, at least you can be conversant with Medicare’s list of payable diagnoses (codes that support medical necessity) for each CPT code. These are readily available online.
SOME YOU WIN; SOME YOU LOSE For contract negotiations, like many things in this world, “might makes right.” For “might,” please read “market share” in managed
care negotiations. Some of the things that we mentioned above are only feasible if the radiology practice is part of a much larger practice plan, and even then, it is a battle. But for even a small group, there is no harm in trying.
Brian J. McKee, MBA, is from Drexel University College of Medicine, Philadelphia, Penn. Robert L. Siegle, MD, MPA, Drexel University College of Medicine, MS206, 245 N. 15th Street, Philadelphia, PA 19102-1101; e-mail: [email protected].
Comments on “Negotiating in a Managed Care World” Brian J. McKee, MBA, Robert L. Siegle, MD, MPA “Negotiating in a Managed Care World” provides a broad range of excellent advice. We have a few additional items that you might want to consider for the negotiating process. These fall into the category of lessons learned. CREDENTIALING Provider credentialing means more than just adhering to the insurer’s rules about what makes a physician acceptable as a provider. It means dealing with the delays built into the process, some unavoidable and some willful. Always negotiate for the shortest possible response time from the managed care company. Aim for 60 days from start to finish. Even if you follow the process diligently and completely, the companies may take months to assign provider numbers. This issue can be addressed in several ways. Make sure the requisite materials are complete and up to date when they are provided to the managed care companies, so that the insurer does not have an opportunity to return the documents and delay the process. Delay the new radiologist’s start date until some or all of the provider numbers have been assigned by the group’s primary payers. In the current recruiting environment, this approach works best when you have a long lead time to employment, such as recruiting from residency or fellowship programs. As part of the recruiting process, make sure that you assist residents or fellows with applications for their full unrestricted medical licenses and DEA numbers, when850
ever appropriate, while still in training. Both of these may be required documents in the managed care credentialing process. Alternatively, it may be possible to negotiate standards with the payers. Such standards could include reimbursement for services rendered before that provider number is issued, especially if there are unreasonable delays in obtaining the provider number. Another option would be to negotiate with the managed care company to pay for inpatient hospital services regardless of the participation status or alternatively to bill using a participating group number rather than waiting for an individual provider number. A possibility for large physician groups is negotiating delegated credentialing. Delegated credentialing transfers the responsibility for credentialing from the managed care plan to the provider group. The group must demonstrate the ability to take on the credentialing functions the plan would normally perform. In exchange for taking on this process, the group is able to have physicians credentialed on, or very close, to their start dates. As a last resort, you might consider assigning the newest radiologist employee responsibility for reading the lowest reimbursed modality as often as possible to minimize revenue loss until provider numbers are obtained. CLEAN CLAIMS AND TIMELY FILING The insurer’s failure to meet any “clean claim” limits should include
interest on delayed payments. Check out your state’s prompt-pay laws and understand how interest is paid, because this might add up to significant dollars on high-ticket items that are not paid in a timely manner. All of your managed care contracts will have timely filing clauses. In contrast to what the authors state, our experience shows that managed care companies will have a single timely filing limit for both inpatient and outpatient services. Negotiating 180 days for timely filing is preferable, for the initial claim submission, as well as an additional 180 days for the claim appeal process. REIMBURSEMENT ISSUES Radiology services are generally reimbursed 1 of 2 ways: fee for service, as the authors discuss, and capitation, which is a prepaid amount of money paid per member per month to the radiology group to provide certain services regardless of member use. As the authors indicate, it is very important to negotiate higher fee-for-service reimbursements for high-volume procedures. Additionally, you will want to maximize the number of high-end services that are excluded from capitated contracts. To be successful, radiologists must be aware of their historical service mix (volume by Current Procedural Terminology [CPT] code by payer) and obtain a CPT-specific listing of capitated services. There is perpetual concern about payable diagnoses for each CPT code. Each managed care company may have its own nuances for these
© 2005 American College of Radiology 0091-2182/05/$30.00 ● DOI 10.1016/j.jacr.2005.04.002
Commentary 851
things, and they are probably averse to sharing them with you. But, at least you can be conversant with Medicare’s list of payable diagnoses (codes that support medical necessity) for each CPT code. These are readily available online.
SOME YOU WIN; SOME YOU LOSE For contract negotiations, like many things in this world, “might makes right.” For “might,” please read “market share” in managed
care negotiations. Some of the things that we mentioned above are only feasible if the radiology practice is part of a much larger practice plan, and even then, it is a battle. But for even a small group, there is no harm in trying.
Brian J. McKee, MBA, is from Drexel University College of Medicine, Philadelphia, Penn. Robert L. Siegle, MD, MPA, Drexel University College of Medicine, MS206, 245 N. 15th Street, Philadelphia, PA 19102-1101; e-mail: [email protected].