We learned that effective Oct. 1, 2018, we will not be paid T-Code (an all-inclusive rate) by Medicaid for autism patient visits. Instead, we will be paid at a fee-for-service rate that we need to negotiate. As a new CFO, my challenge is that I have never negotiated payer contracts, and I’m seeking advice from experts in this area to advise me on how I can negotiate. What data do I need to arm myself and the CEO with when going to the negotiation table?
Answer 1: Here is a list of items you should know prior to walking into payment negotiations with health plans:
- Your charges versus the charges of your competitors
- Average payment of your competitors as available through publicly reported data
- Your cost to provide the service and the cost of your competitors, which may be found through Medicare cost reporting and other sources
- Quality indicators (e.g., mortality, average length of stay, etc.)
- Number of competitors in your market (in general and specific to the service)
- Your expertise versus competitors in this market (e.g., subspecialties of physicians, year offering service, ancillary services necessary to provide the service)
While I know that all of this may not apply to every situation, this checklist should be a good starting point to gather the necessary information to assist you in negotiations.
This question was answered by: Curtis H. Bernstein, CHFP, CPA/ABV, ASA, CVA, a principal, Pinnacle Healthcare Consulting, and a member of HFMA’s Colorado Chapter.
Answer 2: I don’t specifically work with autism claims, but I can make general remarks about payer negotiation.
Make sure you know your charge data. How many patients are you seeing for autism? Is it a growing area? How much variation is there among your providers and how they treat patients with autism. Is there evidence that your outcomes are betters in a way that could save the payer money? Sit and talk to the clinician in charge of the program to find out what your competitive advantage is.
Is this the only service you provide or are you negotiating with the payer on a group of services? If you are negotiating for other services, you may lose on some and others do well on others, depending on the health plan’s agenda.
Who are the providers (perhaps pediatricians in this case) who tend to refer patients to you? The health plan may want to keep you in-network if those physicians are in-network, which gives you an advantage.
This question was answered by: Ruth Landé, vice president, patient revenues, Memorial Sloan-Kettering Cancer Center, and a member of HFMA’s Metropolitan New York Chapter.
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