Many believe that this effort will be wasted, as taxpayers will do what they do regardless of whether we approach them. You may be wondering what power you really have to influence the suits in the elegant building. In this article, I’ll cover why, why now, and how.
first, what do we mean by insurance companies or payers? traditionally, insurance companies are those companies that collect a premium from individuals or employers and pay for health services according to coverage policies.1 the same insurance company, to supply a network of contracted physicians, process claims, and provide other infrastructure, such as care management and provider relations. the company name on the patient card may be the same as for a fully insured patient, but the liability is different. self-insured employers can set their own benefits, including what services they cover.
the largest payer in the united states is the federal government, through medicare, medicaid and other programs.2 under traditional fee-for-service medicare, the center for medicare and medicaid services (cms) contracts with intermediaries that settle most local policy and process claims. Although we cannot negotiate rates with brokers, we have the opportunity to advise brokers and influence local hedging policies.
the medicare advantage (ma) option (medicare part c) continues to grow.3 under ma, cms contracts with private payers (those same insurance companies) and uses their networks, transferring financial risk to that plan. To be in-network on a MA plan, you must have a contract with that payer and follow that payer’s policies. CMS also has a contract with ACOS and has moved forward with the Bundled Payment Care Initiative (BPCI), which also financially rewards entities that manage the care of patient populations. to benefit financially, you must be a member or have a contractual agreement with the aco or entity that has the cms bpci contract.
states, which along with cms pay for medicaid, are encouraging more and more managed medicaid plans. The same private insurance companies will contract with the state to cover the care of Medicaid patients and accept the financial risk. In recent years, many patients have been added to managed Medicaid plans through the Patient Protection and Affordable Care Act (ACA).
If you participate in a risk contract or aco, you may still be paid a fee-for-service through the insurance company. However, as physicians, hospitals, and others take on greater responsibility for the care of patient populations, spurred on by health care reform, the ACA, and the Children’s Health Insurance Program Reauthorization Act and Medicare Access Act 2015 (macra), neurologists need to be more aware that many of the decisions about how we participate in any distribution of savings are determined not by the insurance company, but by peer-led governance structures.
The payer may still pay for each visit or procedure4: However, an increasing portion of what we take home will be based on the quality of care we provide and our stewardship of resources. The large primary care medical group, the ACO in the community, your faculty practice plan, or all 3 will establish standards of care, quality metrics, resource usage, and interaction policies that will largely determine your financial success. . are left.
For the purposes of this article, I use the term payer to refer to the insurance company, ACO, government broker, or government of your department, hospital, or practice plan. the payer determines how you get paid and shares any rewards based on how you practice.
Despite decades of urging physicians to change the way we practice, physicians and organized medicine have not been effective in implementing models that slow the growth of health care spending. largely through the policy-making ability of cms, as well as the passage of the aca and macra, change is here. For us to be successful, we will need to work closely with the entities that are defining the rules.
The first thing that comes to mind is how much we get paid for what we do. Traditionally we think of how much we get paid for each unit of service, whether it’s an office visit, hospital care, or a procedure, such as an EMG or EEG interpretation. As health care reform moves forward, we must agree on how to measure the quality of care we provide and the value we provide (value = quality divided by cost). it is necessary to give an opinion on coverage policies, such as intraoperative follow-up, or the use of botox for headaches. we need to influence treatment guidelines. we need to show that what was an expense in the past (a visit or a procedure) is now an investment (better patient outcomes, lower overall costs).
There are several common strategies that are specific to the type of practice you’re in, whether it’s a neurology group, a multispecialty group, or an academic foundation. These may vary if you are working with a commercial private payer or ACO. If you are one of several neurologists in a neurology practice or in a multispecialty group, it is important to speak with one voice: any differences should be resolved behind closed doors.
Determining your goals is the most important task.5 Consider going through a structured process, even if you’re an independent neurologist. almost everyone starts with the refund. however, reducing administrative hassles, changing policies that affect your practice, or finding ways to handle complex patients will also help your bottom line. If you will be working with an academic, multispecialty, or ACO group, your goals will revolve around how to manage patients and work with colleagues in other specialties.
It’s also important to find common ground with the payer, as this will help set the stage for a productive conversation. consider the difference between starting with “you need to pay me more because my patients are sicker and more demanding” and “my practice includes many complex patients who may benefit from some of the care management programs you (or I) offer “. many patients with neurological diseases have complex health care needs, often requiring expensive diagnostic imaging and medications. Who best understands how to manage all this profitably? neurologists.
Insurers know a lot about you, based on claims. they aggregate data, such as images, medications, referrals, admissions, and emergency department visits, as well as quality metrics around severity-adjusted episodes of care for specific diagnoses.
Basic data for your practice will include the work you do, what you get paid for each service you perform and by each payer, as well as the mix of patients by age, diagnosis, and payer in your practice.6,7 working with their staff will give you information on how easy it is to do business with the different payers: if it is very difficult and time consuming to collect what is owed to a payer, it costs you time and money. it’s also important to know how you perform on standard quality metrics, patient satisfaction measures, and referring physician satisfaction measures.
It is essential to reach the person who makes the decisions on important issues to avoid wasting time and becoming frustrated. this requires knowing the payer.8 For example, if your goal is to reduce the time spent on imaging clearances, your contact will be one of the medical directors. the supplier’s representative is unlikely to be helpful in resolving this issue. If you spend a lot of time arranging for home infusion, then you need to find the director of care management. If you’re looking for a better refund, you need someone on the contract who can get out of a standard fee schedule. If you join an ACO or are part of a multi-specialty practice, you need to find out who will determine how neurology services are priced and how savings are shared.
When you have to choose between working with someone who treats you with respect and someone who doesn’t, who do you choose? In general, you will work with professionals who deal with doctors and office staff on a day-to-day basis. they have probably heard each permutation on a subject a hundred times. this requires that you come prepared to each meeting. Proposals must be in writing, appear professional, and present your position clearly, concisely, and with relevant data.
Clearly you’re in a stronger position to achieve your goals if you’re in a large group.9 If you’re alone or in a small group, implement a longer-term strategy that includes building relationships with key payers . You can do this by participating in payer committees or meeting regularly with medical leaders and using care management resources. patient and referring physician satisfaction, or areas of clinical or program expertise, are excellent differentiators. ask payers for their quality and cost data, and if you’re not at the top, find ways to move there. For example, if you see a lot of headache patients, know what percentage of patients with benign headaches have imaging and what percentage go to the emergency department, compared to others in the payer’s network. If you use the american academy of neurology (aan) headache quality measurement set,10 or other measurement sets, show the results. working in a small practice allows the flexibility to make changes that demonstrate exceptional value to payers.
The imperative in academic medical centers is how to move from hospital systems to health care systems. cms now penalizes centers with high readmission rates, whereas in the past, this was a source of revenue. you negotiate with the hospital or college practice plan and show value for what you do the same way you do with any third-party insurer. this means not only knowing your department’s data, but also the effect your department has on system performance.
chances are the center you work for has a strong recruiting department. there will be committees that include physicians that oversee managed care contracts or joint risk-sharing agreements around patient populations. these are the groups that meet with the payers and also decide internally how profits are shared and how productivity is measured. you want to be at the table to represent neurology. This means that you have to acquire particular knowledge about health care reform, models of care, quality and cost metrics, and payment alternatives. Relying on surgeons or internists to represent your interests is flawed at best.
several taxpayers solve their problems with doctors by exhausting us. they assume, often correctly, that we can’t afford the time or effort to navigate our way through a complex bureaucracy. we tend to tackle problems one at a time, such as a claim being paid incorrectly. they calculate the cost of fixing a systems problem for everyone versus responding to the small number of practices that persist to get their fair share. Is it worth it for a practice to spend an hour to get the $10 owed on a claim?
Very often, the solution is working through someone you’ve built a relationship with, whether it’s that person who works with your practice for a durable solution or connects you with the payer’s responsible decision maker. This is where the time you’ve spent getting to know paying staff in non-confrontational situations pays off. who you know and who knows you makes a difference.
The union is strong if the problem is not resolved or continues to occur. By working with your state society or independent practice association, you can gather information about similar problems from others.11 Consolidating problems as a group is powerful. Please note that antitrust regulations are strict and vigorously enforced. you may not have any discussions with other practices about fees or class actions against a payer. however, if you are negotiating or participating in a risk contract, or an aco deal, you have much more freedom.
The next step is to gather data from your practice and others and work with your state insurance commissioner. Any data you submit to the agency that regulates them is likely to be challenged by the payer, so it’s critical that all your information is airtight. it’s better to focus on 1 or 2 major issues than a list of items with limited supporting documentation.
the aan has opened strong lines of communication with many of the largest national and regional payers over the past 8 years through the payment policy subcommittee (pps). PPS staff and members advocate on behalf of members regarding common practice issues (due to antitrust limitations, PPS cannot discuss reimbursement). through contacting members directly or the “payer relations toolkit” form (https://www.aan.com/practice/payer-relations/payer-relations-toolkit/), issues are identify or consolidate, giving a strong voice to complement and reinforce their local efforts. pps also reviews payer policies on an ongoing basis and provides insights focused on member guidelines, measures, and expert opinion.
Working with payers is a critical aspect of being a successful neurologist. Health care reform requires neurologists in all settings and practice types to be aware of payment mechanisms, policies, and procedures with insurance companies, ACOS, and practice partners, as well as financial, operational, and quality of your practice. it is necessary to set goals for relationships with payers and implement strategies to achieve the goals.
See also: Medi-Cal Member Services