HEALTH (CONTRACTS - PAYER) | Marc Cunningham LLC

Health (Contracts – Payer)

Negotiation and drafting of agreements, contracts, documents and templates, such as for: health maintenance organization (HMO); independent practice association (IPA); insurer health plans; physician-hospital organization (PHO); preferred provider organization (PPO); third-party payer-provider.

Consultation for providers with regard to providing services under Medicare and Medicaid.

Training for providers to ensure a complete understanding of the applicable provider regulations before they execute a third-party payer contract, to avoid liability and penalties under Federal or state laws.

Negotiation strategies for providers in aspects of contract formation and disputes with health insurance payers.

Experience with government and private reimbursement, reimbursement in integrated delivery systems, and all aspects of the payment cycle for healthcare services and audits.

Experience managing disputes in all payer segments, including Medicare Advantage plans, Medicaid managed care plans, Tricare, HMO plans and PPO plans.

Management of all stages of payer and reimbursement disputes, including administrative proceedings, appeals, arbitrations, audits, investigations, litigations, mediations.

Legal support for Medicare audits and appeals, including issues related to statistical extrapolation and sampling.

Negotiations with Medicaid Managed Care Organizations (MMCOs), denials of payment and coverage cases.

Application of the Medicare Resource Based Relative Value Scale (RBRVS) and Relative Value Unit (RVU) as benchmarks for negotiating many payer contracts.

Experience with contracts for durable medical equipment (DME) and home medical equipment (HME).

Successful resolution through negotiation of disputes resulting when the payer declines to reimburse the provider for a service, claiming that service is either not covered or not medically-necessary.

Legal support for the lifecycle of a contractual relationship, including consultation about the contractual dispute resolution mechanism for the provider to appeal reimbursement denials, duration of the payer relationship, early termination options for both parties, reimbursements rates for services, scope of services for which the payer agrees to provide payment, and the specific state law contracting requirements.

Close collaboration with payers and health systems to structure incentive compensation pools, payment withholds and sharing arrangements that are compliant with Federal and state laws and help achieve cost savings for all participants.

Consultation for providers with regard to providing services under Medicare and Medicaid.

Representation for providers and suppliers, such as ancillary providers, health care systems, hospitals, post-acute and durable medical equipment suppliers, skilled nursing facilities, in a range of matters related to Medicare reimbursement disputes before Medicare administrative contractors, state Medicaid agencies and the Centers for Medicare and Medicaid Services (CMS).

Discussions, meetings and negotiations with CMS administrative contractors and other payers, for the purpose of removing or reducing prepayment reviews.

Strategic challenges for providers when considering joining health insurance or managed care networks, such as reducing administrative complexity, reducing the financial burden on patients, a more reliable revenue stream, stabilizing reimbursements and potentially an increase in referrals.

Consultation regarding points of consideration for providers when negotiating to join a payer network, such as attempting to anticipate how the contract may apply to new lines of business or insurance products that are introduced after the contract commences, how the long-range strategic plan the provider already has may be affected by this new relationship (and whether such strategic plan may need massive revision if the negotiations are successful), knowing the provider’s own internal costs going into the negotiations (and being able to justify the fairness of such costs though verifiable data analytics) so as to effectively compare them with reimbursements and then determine whether the potential relationship is financially viable, negotiating a built-in rate increase in the contract rather than relying on negotiations at the time of contract renewal, clear definitions for all terms, negotiating rates before going through the credentialing process, clarifying the language and parameters for take-backs, verifying (through their own internal compliance procedures and protocols) prior to negotiations that they will be able to survive any state and Federal audit requirements (if the payer has Medicaid or Medicare managed care offerings), the impact on anticipated reimbursements if the payer wishes to adopt a value-based reimbursement program during the term of the contract.

Consultation regarding particular payer contract areas of concern to providers, such as clarifying the definitions (such as, “allowed amount”, “clean claim”, “eligible expense”, “medical necessity”, “medically necessary”, “negotiated rate”, “payment allowance”), the fee schedule (which should be attached to the contract as an exhibit, and must be an as complete as possible enumeration of every possible expense for which the payer will reimburse the provider),no (or at least severely reduced) ability for the payer to make unilateral amendments to the contact after execution, term (typically one year, either without any automatic renewal periods or with very clearly defined renewal options), termination (either for cause, with an allowable cure period, or without cause based on mutual agreement regarding separation costs), and in situations when there may be more than one payer, clear coordination of benefits (CoB) rules to define the order of payers for each of the applicable line items in the fee schedule.

Negotiating with plan sponsors regarding potentially unlawful plan terms.

Representation for providers in disputes with insurers, including terminations of provider agreements.

Evaluating denied claims against the terms of the provider-payer contract, then assisting providers determine how to proceed against perceived payer improper denials, and helping providers recover damages caused by such improperly-denied or underpaid claims.

Evaluating questions of fact, such as prior authorizations and legal questions such as potential violations and penalties.

Enforcing insurer and payer compliance with preferred provider arrangements, third-party network contracts and treatment agreements.

Challenging payers who violate the Medicare Secondary Payer (MSP) Act and other CoB rules, audit findings, overpayment demands and recoupment actions issued by third-party administrators, insurers and health plans, and plan fiduciaries for failing to follow proper claims and appeals procedures.

Familiarity with general payment models for payer contracts, such as the pure fee-for-service (FFS), in which the provider is paid a set rate per service provided; such service is most often defined by a current procedural terminology (CPT) code, based on the Medicare fee schedule multiplied by a multiplier negotiated between the payer and the provider; such CPT code is matched against the International Classification of Disease (ICD) diagnosis code by the payer; the provider submits the claim to the payer, which then makes a determination to pay all or part, or to deny, or to request further information from the provider – pure capitation – the payer makes a fixed payment to the provider based on a payment schedule; more beneficial for primary care providers than for specialists – global capitation – a blended form of FFS and pure capitation, with shared risks and savings, pay-for-performance (P4P) and total medical expenses (TME) responsibility – episode-based payments – bundled services calculated on a pre-episode rate; may be consumer-driven, thus burdening the patient with higher deductibles.

Recommendations to executive management and all relevant stakeholders to perform a self-critical strengths, weaknesses, opportunities and threats (SWOT) analysis prior to negotiations to offer pre-negotiation opportunities for improvement and to avoid miscommunication of the facts during negotiations.

Authored and managed an accurate payer matrix (listing key payer data, including key payer personnel contact information, phone, fax, email, current and historical reimbursement terms, key provisions in the contract as related to particular services).

Designed and implemented a robust provider contract management system and searchable contract repository database, including master data for fee schedules, reporting needs for account management and reviews, payer snapshots and other tools and processes as required.

Negotiated, drafted, maintained and administered all contracts within the enterprise, including payer contracts.

Responsible for the accuracy of supporting contract documentation and completing all documents and filings accurately.

Facilitated the approval process of all contract documents from pre-contract through post-contract signature phases.

Worked with credentialing and all relevant involved teams to insure contracts are compliant with all relevant statutes, regulations and corporate policies.

Monitored all contract deadlines and conditions to ensure timelines are kept and that all relevant information has been collected and input into the contract repository database.

Provided contract summaries and ensured contract execution in accordance with corporate policies.

Provided periodic reports to senior management and organizational stakeholders, with the progress and status of contracted payer agreements.

Management of contract administrators for payer contracts, to ensure that productivity objectives were met.

Performance management and continuous recalibration of administrative staff, ensuring appropriate staffing levels and resource allocation.

Administrative tasks such as timekeeping, performance, policy administration and other matters related to employment.

Assessed the capabilities of staff, and then provided feedback regarding technical proficiency and effectiveness.

Designed and presented contract training programs and playbooks, to ensure that staff knowledge was current.

Maintained payer relationships and acted as the liaison between other internal operating units and external payers.

Developed contracting strategies which resulted in preferred relationships with key payers.

Legal support for requests related to direct referrals, automation of authorization (system and portal) and single patient price negotiations (non-contracted payers).

Last updated 20509_1435