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A Blueprint for Success, Effectively Negotiating Third Party Physician Payer Agreements

Course Module 1 – October 8, 2013 – 3 p.m. EST
Course Module 2 – October 15, 2013 – 3 p.m. EST
Course Module 3 – October 22, 2013 – 3 p.m. EST
Course Module 4 – October 29, 2013 – 3 p.m. EST

       

This program comprised of 4 individual course modules, spanning a period of four weeks, is designed to teach students the skills to negotiate fair reimbursement from third-party payers and to employ useful tools which can effectively monitor payments to ensure contract compliance and also to provide data for future negotiations. This course includes online reading assignments, WebEx-type lectures and workshops plus a four-month license to utilize the contract monitoring software, HealthcentsRevolution™ software, developed by Healthcents.

Whether it is with a major commercial insurance plan, a Medicare Advantage plan or an independent provider association, enhanced contract negotiation skills will generate healthy returns for urology practices. With the increasing emphasis on the concept of accountable care organizations (ACOs), urology practices will also be negotiating contracts with their primary care colleagues who have formed ACOs as well as fee-for-service contracts with their regular payers. This training will prepare you for this new negotiation effort and will enhance your value to your employer. This training will provide a flexible schedule for students to carry out some of the assignments so they can work at their own pace. The WebEx events will be prescheduled but the reading assignments and projects will be self-paced with deadlines for completion. See the detailed program agenda for each of the four course modules below.

This education is designed by Susan Charkin, the CEO of Healthcents, an expert in the field with experience negotiating from the payer side and also the provider side. She is an experienced instructor who is passionate about helping her clients and her students be successful in negotiating fair contracts for payment.

Read testimonials from previous students of this program.

"I feel like I have sufficient tools to negotiate when our biggest payer responds again. Thanks for everything you have done. I really appreciate having a slice of your knowledge. "

Kyle Watson, participant in Class 3
Practice Manager

Florida

"Contract negotiation is a very timely issue. Rather than assume that nothing can be done with insurance contracts, all managers will benefit from this course and the tools that they give you to help in the process of contract negotiation. The worksheets and software were great; I have done a couple of contract negotiations before but this course gave me a chance to understand it better."

Regina Bash, RN, participant in Class 1
Practice Manager

Pennsylvania

"I love that we will finally have the same information that the insurance companies have."

Shirley Van Hise, participant in Class 1
Practice Manager

California

Course Module #1 – Overview

Objectives – Lay a solid foundation for Managed Care Basics (to be co-presented with AUA government advocate, Medicare specialist and attorney)

 

Agenda

 

Managed Care 101: A history of US managed care / 3rd party payors

 

Glossary of Terms: Insurance and reimbursement definitions
(including other terms identified by AUA staff)

 

What third party payors "don't want you to know"
(methods to mitigate/address these areas)

 

How revenues flow from payers to practices

 

Reimbursement issues: is 3rd party payer contracting right for me?

 

Are you better off being in-network or out of network?

 

What payers are looking for and how they are regulated

 

What is necessary for provider empowerment?

 

How you can leverage PPO licensure and accreditation

 

Overall negotiation strategies

 

Justifications for renegotiations and payment adjustments

 

How to use HealthcentsRevolution™ Software
(Out of Network and Claims Analyzer models)

Course Module #2 – Data Acquisition for the Proposal Letter

Objectives – Prepare an overall negotiation strategy with justifications. Perform a reimbursement and language analysis of a PPO/Third party payer agreement. Change the agreement and what to specifically ask for. Reimbursement statistical modeling and how to evaluate payer proposals and develop counterproposals with high dollar return on investment.

 

Agenda

 

Analyzing and understanding the uniqueness of your Practice

   
  • Market penetration of other urologists

  • Unique/special services only performed by your Practice

  • Local physician referral patterns in your area

  • Are you the only provider in a 25 mile radius? Or, are there many urologists in a 5 mile radius?

  • What are the sub-specialties of your Practice?

  • Who are the physicians who practice?

  • Combining negotiations for multiple health care businesses
    (be careful of Stark, Sherman anti-trust rules)

  • Which payer contracts exist?

  • Which payor contracts are most important? Least important?

  • Competitive benefits of your group vs. others in the area

  • Is your Medicare certified? Any other accreditations/certifications?

  • Any outstanding payments owed by payors (leverage point)

  • Prior year's total billing and collections by each agreement

  • Existing fee structure (CPT codes, billed charges)

  • Top 20 CPT codes (by total revenue volume)

  • Top 20 CPT codes (by total performed volume)

  • Percentage of total business from 3rd party payors
    (commercial PPO/third party payors + Medicare)

   
   
   
   
   
   
   
   
 

Maximizing your reimbursement

 

Detecting problematic rates and language issues

Course Module #3 – Reimbursement Analysis

Objectives – Using the HealthcentsRevolution™ In Network / Out of Network model – determine the breakeven point. When is it worthwhilsoftware, understand the range of analytics that can be performed and the types of "what if" which are easily addressed by this powerful software tool.

 

Agenda

 

Use of the Revolution® software

   
  • In Network / Out of Network model – determine the breakeven point. When is it worthwhile to go out of network?

  • How do your charges compare to others (benchmark data)

  • Evaluate what other similar providers are charging third party payors.

  • How does your payer reimbursement compare?

  • Give your payor the top 40 codes and ask to see how your group's current reimbursement compares to Medicare

  • How/where to get Medicare rates

  • Carve Outs – many payors will pay discreet rates for codes/proprietary fee schedules.

  • Default rate – anything not currently grouped is paid at x% of billed charges.

  • Billed charges or invoice cost + 10% for high cost disposables over $25, implants, prosthetics, lab.

   
   
   
   
   
   
   
   
 

Student Exercises – what to look out for in a third party payor agreement

   
  • Participants will demonstrate competence in detecting problem areas in agreements – what type of language and rates to negotiate "in" and "out" of agreements. This will be a demonstration/Individual exercise.

  • Perform a review of a sample PPO agreement utilizing the Healthcents reimbursement analysis tool

  • Use AMA contracts template in locating key information in the contract (Lecture/Demonstration/Individual exercise)

  • Actual use of the HealthcentsRevolution™ software tool. Effectively review a third party payer agreement for rates and language (2-3 samples).

Course Module #4 – Preparing the Proposal Letter and Negotiation Tips

Objectives – Preparing and sending a Proposal Letter. Understand what PPOs and third party payers "don't want physician practices to know" and specific methods for addressing and mitigating. What to do when you get pushback for the payer. How to "sell the physician" to the payer. And, finalizing negotiations and how to close out.

 

Agenda

 

Utilizing data analysis and preparing the proposal letter

   
  • Template proposal letters

 

How to "sell the physician" – most third party payer negotiators get between 30-40 calls a day from providers wanting to join their networks. How do you get to the top of the list to negotiate or re-negotiate an agreement?

   
  • The mystery of contacting a third party payor

  • Getting to the right person/department

  • Getting a call back from the contractor

  • Completing you negotiations in record time (A "How'to" Guide)

 

Getting to "Yes" – What to say when you get "pushback" from third party payors

   
  • Payors will state that they have different departments for hospital, ancillary and physician contracts and don't have the budget for your increase

  • Payors will say that they cannot give us the rates as our competition offers lower rates than we do and the payor will drive additional business to our competition if we don't sign up for the rates that they want

  • Payors will say that if you are non-contracting, patients will choose in-network providers because they are cheaper

  • Payors will tell you if you don't contract that they will send the payments to the patients

    • Students will be given the tools to know how to navigate these types of scenarios

 

Should you sign it? Tracking ROI utilizing the HealthcentsRevolution™ software tool

 

Executing a PPO Agreement – Tips on Completion

 

Student Exercises

   
  • How to establish and write a proposal letter (Individual Exercise)

  • Mock negotiations (2-3 samples)

For questions, please email AUA Practice Management at pracman@AUAnet.org.

Price: $1,499.00

Cancellation Penalty
If cancelled not later than October 1, no penalty. Cancellations received after October 1 will be charged $150.

Computer Specs
High speed Internet connection with one of the three player software packages

Following are valid Players for rich media files using a Universal Communications Format (UCF)

  1. Flash Player 6.0 or later
  2. Windows Medial Player 9.0 or later
  3. Quicktime 7.1 or later
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