Payer Contract Renegotiations: Improving Your Negotiating Skills

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Timely and correct reimbursement is always top of mind for a healthcare provider. However, many providers are leaving money on the table due to infrequent payer contract renegotiations.

Due to the nature of payer contracts, which includes fee schedules, reimbursement requirements, as well as conditions payers must meet for timely reimbursement. Therefore, payer contract negotiations are a vital component of a healthy revenue cycle.

Basics of a Payer Contract

Payer contracts are legal documents, and it is essential to have a firm understanding of the fine print. This will help your organization capture all charges and prevent claim denials. It is usual for providers to know the reimbursement rates for their most commonly billed services. However, there are other core elements that they need to be familiar with that can create challenges for revenue cycle management.

Here are eight other critical areas of a payer contract that need to be reviewed and understood:

  • Timely filing: Payers set time limits for filing claims, and your practice must know what those limits are to ensure timely filing. While most practitioners send claims quickly, it is good to understand the time limits for anything that may fall through the cracks.
  • Unilateral Amendments: Every contract has a section pertaining to the process by which a contract can be amended or the ability for the parties to revise the agreement. Some of these contracts allow for changes to be made by the payer without consent from the provider. It would be best if you tried to ensure that the contract can only be amended by mutual agreement, in writing, in advance, and by both parties signing off on the change. Or at least state in the contract that you are to be notified of any revisions before they go into effect and given time to craft a response.
  • Prompt Pay: The contract’s language should be specific regarding the reimbursement practice for all plan products for correctly submitted claims. This should be within 30-45 days of receiving the claim or follow your state’s regulations if there are any.
  • Over/Underpayment: This language refers to the timeframe both parties have for limiting how far back either can go to collect or refund an over or underpayment.
  • Termination: This language is specific to either party’s ability to exit the agreement without cause within a fair amount of time.
  • Assignment/mergers: Any language about assignment or mergers should be reciprocal to the payer and provider. Payers frequently enter into mergers and don’t ask permission from practices. Practices should have the same freedom to conduct business transactions, whether it is a merger or assigning a contract.
  • All Services: This contract language should allow practitioners to provide and be reimbursed for all services that fall within the scope and expertise of their specialty and license so as not to limit them to a specific set of services.
  • Arbitration: The contract should contain appropriate and reasonable arbitration language, ensuring that both parties can access all legal protections. Proper jurisdiction, as well as clear time frames and cost responsibilities, are critical. Also, the contract should be governed by the laws of the state where the practice is located and not the payer’s headquarters.


Preparing to Negotiate

You need to make sure you have copies of all contracts to see where you currently are with them and determine where you want or need to go. Have all your contracts in one easy-to-access place; if you can’t find them, request a copy from the payer.

When getting ready to negotiate, you must clearly understand your payer mix. Looking at your entire book of business will help to determine where you are paid the least, the most, and what representation of your patients are under which payers. This will allow you to decide which payers and services to focus on. Other information you need to have to help in your negotiations are details that can help you articulate the story and value of your practice, such as your technology, affiliations, patient population, range of services you offer, what sets your practice apart from your competitors, and the overall goal/purpose of the practice.

Here are five points of negotiation that can help:

  • State laws apply: You should be aware of your state laws and how they affect insurers’ way of conducting business. There may be rules governing timely payment or even takebacks.
  • Be aware of the contract term: Many insurance payers try to get providers to sign long-term contracts, three years or more. If this is the case, does the contract cover built-in increases to keep pace with inflation or other considerations? Usually, they don’t.
  • Make sure rates are transparent: Understand what the rates are based on, whether it be Medicare or a proprietary fee schedule. If Medicare, is it the current or another year? Is there more than one plan under the payer? If so, do you have a fee schedule for all of them?
  • Know the payer: In addition to bringing data from your practice, conduct research to better understand the payor’s specific concerns and areas of focus. For example, if the payor is concerned with minimizing hospitalization rates, bring data to the table showing how your practice has addressed ongoing healthcare, lowering patient hospitalizations.
  • Know your value: Payors respond the best to facts and data. Knowing your worth and quantifying all aspects of your practice can help get you higher reimbursement rates.

You should also develop clear objectives of what your organization expects to gain from the negotiations, whether to increase net yields, boost a specific service line, or enhance payment accountability. But, be prepared for anything by having data-driven, evidence-based responses to potential questions. You can be ready for these by brainstorming with organization stakeholders such as other practitioners, financial leaders, or practice administrators to develop ideas on what the payer may expect from the negotiations and how they may react to your requests, thus putting yourself in a better place to negotiate.

Also, getting input and agreement from key stakeholders can ensure you are flexible where you can be and stand fast on the terms that provide a better outcome for your healthcare organization. You can even determine if there is a point where you are willing to walk away.

Benefits of Negotiating Payer Contracts

It is agreed that contract negotiations can be intimidating, but there are many benefits to be gained by taking the time. Not only does this build relationships with payers, it also can keep the practice top of mind of the payer’s network providers. In addition, it allows practices the opportunity to demonstrate their value to payers while offering clarity on issues within their specialty. In the end, successful negotiations can result in higher reimbursement for services and contract language that protects the business interest of the practice.

Building relationships with payers helps create a strong foundation for negotiations. It is suggested that practices sit down annually with their payer representative to:

  • Introduce practitioners
  • Provide education about the practice’s specialty and value proposition
  • Learn payer’s needs and find opportunities to collaborate

By doing this, you maintain close contact with the payer representative, which can support a mutually positive outcome regarding negotiations.

Getting Help with Your Payer Contract Renegotiations

With all the other things that need to be managed daily, who has the time to establish a comprehensive payer contract management process to handle the complexity of managing multiple contracts. It is hard for a practice to keep up without getting discouraged by the process as it can be lengthy and complicated.

At Billed Right we understand how stressful and time-consuming contract renegotiations can be. Taking the time to review your payer contracts to understand where you currently are can be overwhelming. You also need to analyze your data to determine which payers, plans, and services drive the most value, or the least, consuming even more time and resources. But there is a way to save yourself the time and cost of doing all of this yourself – outsourcing.

Billed Right has a dedicated team of experts who can help prepare and negotiate your payer contracts. In addition, we work closely with you and your team to ensure a solid understanding of your analytical data and what makes your practice unique and work hard to increase reimbursement amounts.

Contact us today to learn more about how we can help you negotiate your payer contracts.

Social Determinants of Health and It’s Utilization in Healthcare

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Utilization of Social Determinants of Health in Healthcare  

Social determinants of health (SDOH) refer to the non-genetic and non-medical conditions in the places people live, learn, work and play that affect health and quality-of-life risks and outcomes. Factors such as economic stability, education, food, housing, transportation, community, and social situations all feed into the social determinants of health. In recent years these have begun to be utilized in promoting health and health equity. It has been determined that a patient’s care journey is 80% dependent on non-clinical factors such as socioeconomic or environmental.   

Our current health system is moving toward a value-based model which incentivizes positive results rather than individualized treatments and procedures. With this shift, healthcare leaders increasingly regard social determinants of health as a critical part of overall healthcare efforts and indicators. By including these facets with standard medical care, providers are taking a holistic view of their patients and enhancing patient care, promoting better outcomes, and driving value.  

There are a growing number of initiatives to address SDOH within healthcare and outside of the healthcare system. Outside, these initiatives aim to shape policies and practices in non-health areas in ways that promote health and health equity. Within the healthcare system, collecting this data can help improve quality and care coordination by identifying social risks and unmet needs such as homelessness or lack of transportation. In addition, they can help to determine healthcare and services follow-up and to plan a patient’s discharge from a hospital situation. Understanding the external factors that can impact a patient’s overall health can also trigger needed referrals to social services that can help meet that individual’s needs.   

Recording Social Determinants of Health 

It has been established that any member of a patient’s care team can collect social determinants of health data during a visit. This includes providers, social workers, community health workers, case managers, and nurses. This data, once gathered, is then recorded in the patient’s health record.   

When ICD-10 codes were first released, they included codes that encompassed SDOH. Some of these “Z” codes are:  

  • Z55 – Education  
  • Z56 – Employment  
  • Z59 – Housing and Economic  
  • Z60 – Social Environment  
  • Z61 – Live Events  
  • Z62 – Upbringing  
  • Z63 – Family and Social Support Issues  
  • Z64 – Certain Psychosocial Circumstances  
  • Z65 – Other Psychosocial Circumstances  

These codes were established to better understand what is happening outside of physical health that can contribute to a patient’s overall well-being. For example, access to public transportation affects a person’s ability to go to work, get healthy food, healthcare, and other important health and wellness factors.   

Z Codes Not Widely Utilized  

According to the American Hospital Association, the Z codes are being utilized infrequently. Reasons range from the codes not being part of reimbursement to not having time to ask the necessary questions during the encounter. As the landscape of healthcare shifts more and more toward value-based care, this information will become extremely important to ensure favorable outcomes in a patient’s overall health.   

Several national initiatives are gaining traction concerning SDOH, including Healthy People 2030 and The Gravity Project. Utilizing these codes can allow for trends to be identified and community-based programs to be started in areas that need social services and prevention programs. And according to the Kaiser Family Foundation’s 50-state Medicaid budget survey, several states require Medicaid MCOs to address social determinants of health as part of their contractual agreement. In addition, in 2018, the CHRONIC Care Act expanded coverage under Medicare Advantage plans to include non-medical interventions. These include transportation to medical appointments, meal delivery, and home improvements that add accessibility, such as installing a wheelchair ramp or handrails.   


It has been acknowledged that one of the most significant challenges related to social determinants of health is the lack of a consistent definition and agreement around what truly is a social determinant. Also cited was the lack of standardization and validated SDOH measures as a major barrier. The concern is around different entities utilizing different methodologies to measure SDOH making comparisons through populations and changes difficult. The thought is that states need to agree on standardizing the various data collection approaches and then incorporating the information into EHRs. Without a uniform reporting and collecting method, the ability of agencies, health plans, and providers to share data and use SDOH to guide their strategies, care planning and make referrals is very limited.   

The other challenge that must be overcome is the lack of interoperability between technology systems like third-party SDOH tools and electronic health records (EHRs).   

Social determinants of health codes can be very powerful tools to collectively measure and evaluate social determinants of health on a national scale. These external factors affecting patients’ health can justify risk adjustment payment methodologies, higher levels of evaluation and management services, prolonged services, extended monitoring, etc. Utilizing these codes can greatly impact public health issues if providers and coders embrace the importance of including these in their comprehensive clinical documentation.   


Who is Billed Right?  

In 2006, two business partners envisioned creating holistic services that help improve medical billing operations. They started by listening to doctors and building a service model around what doctors need the most. As a result, Billed Right’s Revenue Cycle Management (RCM) model was born. The focus continues to be on solving the problem rather than selling a product. Hence, Billed Right’s advanced RCM model revolves around personalized service in today’s corporate world while still cutting costs and improving patient care and practice revenue. As a strategic partner, we look to streamline your revenue cycle and operational management, thus helping you to grow your healthcare practice.  


Contact Billed Right to learn more.   

OIG Exclusion List – What Is It and How Can It Affect Your Practice?  

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There are many rules and regulations around accepting Medicare, Medicaid, and other federal healthcare programs. And if you are a practice that accepts and bills for these federal government programs, it is your responsibility to ensure you are protecting patients from things such as fraud and abuse. To that end, you need to know the exemption status of all employees, contractors, and vendors. Not knowing and having someone on staff, or utilizing an excluded vendor, can lead to significant consequences such as substantial fines and loss of your ability to participate in Medicare and Medicaid.  

What is an Exclusion?  

An exclusion is an extreme civil sanction imposed on individuals or entities by the Department of Health and Human Services, Office of the Inspector General (OIG). This occurs when a healthcare provider or vendor is convicted of a crime such as fraud or theft, license revocation, or has engaged in professional misconduct, abuse, or neglect. These individuals are then excluded from working with or for a healthcare program that is federally funded.   

There are two types of exclusions on the OIG list and multiple ways you can end up on it:  

Mandatory Exclusions: (minimum of five years, can be longer or indefinite)   

  • Felony conviction of Medicaid or Medicare fraud  
  • Felony conviction of substance abuse, including alcohol  
  • Patient abuse or neglect  
  • Felony conviction for other healthcare-related fraud, theft, or other financial misconduct  
  • Felony conviction that relates to the unlawful manufacturing, distributing, prescribing, or dispensing of controlled substances, and more  

Permissive Exclusions: (this is discretionary and can be for up to 5 years, but usually 1-3)  

  • Misdemeanor convictions related to healthcare fraud  
  • Misdemeanor conviction of substance abuse, including alcohol  
  • Misdemeanor convictions relating to the unlawful manufacturing, distributing, prescribing, or dispensing of controlled substances  
  • Default on a federal student loan  
  • Submission of false or fraudulent claims to a federal health care program and more  

Getting Removed from the List  

A provider or entity on the exclusion list can get removed once the exclusion period has expired, but they have to apply for reinstatement. It is not automatic. To start the reinstatement process, you must fax or email the request to OIG with the following information included with the request for removal from the exclusion list:  

  • Individual’s or entity’s full name (which the exclusion is under)  
  • Date of birth for an individual  
  • Telephone number  
  • Email address  
  • Mailing address  

If eligible, the OIG will send the statement and authorization forms to be filled out and returned. Once they have reviewed the completed forms, the OIG will send a written notice of reinstatement or denial. This isn’t a quick process and can take up to 120 days or more to complete.  

How to Ensure You Are Compliant  

Even if unintentional, a mistake can get you into serious trouble with the OIG. Sanctions for violations can reach as high as $10,000 per service item claimed and an assessment of up to three times the amount claimed for each service or item, meaning the penalties can add up quickly and run into the hundreds of thousands of dollars. In addition to financial liability, you can end up on the list yourself and lose your ability to bill any federally funded healthcare program such as Medicaid and Medicare.    

But there is help! The OIG provides a resource that can help you avoid exclusion errors and keep you in good standing with Medicare and Medicaid, avoiding expensive penalties. The resource available is called the List of Excluded Individuals and Entities (LEIE) and is updated when individuals or vendors are excluded from being able to bill Medicare or Medicaid.   

Using the LEIE list can help keep you from accidentally contracting with a vendor or hiring an employee who has been designated excluded from billing with federal government programs. Without this list, your practice could have significant enforcement actions against it. Or worse, you could end up on the exclusion list yourself and unable to see, or bill for, patients on Medicare, Medicaid, or other government programs.  

Utilizing Exclusion Lists  

Checking the OIG LEIE list regularly can help to alleviate situations where you hire or contract with someone on the list. The database includes over 60,000 people, vendors, and entities excluded from federal government healthcare programs and is updated monthly. You can search online, or there is a downloadable database. However, the download doesn’t include Social Security numbers or EINs. Therefore, you have to search online to be sure the person you found on the list is the correct one.   

In addition to the LEIE list, if you get reimbursed with federal program dollars and require Government Services Administration approval, you must also check Excluded Parties List System. The people and entities on this list have been debarred, sanctioned, or otherwise excluded from doing business under a federal contract.   

What To Do If You Make a Mistake?   

Situations happen, and should you find an individual or entity on the list with whom you are doing business or are looking to do business, you must take immediate action. The action necessary will depend on the situation:  

Pre-Employment Check: Should you run a check on a potential new hire and they are found on the list, the action is simple – don’t hire them. This does not apply to patient-facing employees such as nurses or doctors but to all employees or vendors that may provide support services and administrative and managerial positions.   

Existing Employee/Vendor: After you have hired or contracted with someone and their name appears on the exclusion list, it isn’t as easy, but there are actions to take to lessen the repercussions. Self-disclosure is the process that will allow your practice to avoid costs or disruptions that could be associated with government-directed investigations or civil or administrative litigation. The downside is that you may still face penalties; however, reporting the situation yourself is much less damaging than if OIG figures it out first.   


It is your responsibility to ensure that you are not hiring or contracting with anyone who is considered excluded from billing federal government programs such as Medicare or Medicaid. A reminder to regularly check LEIE and can help your practice stay compliant.   


Who is Billed Right?  

In 2006, two business partners envisioned creating holistic services that can help improve medical billing operations. They started by listening to doctors and building a service model around what doctors need the most. As a result, Billed Right’s Revenue Cycle Management (RCM) model was born. The focus continues to be on solving the problem rather than selling a product. Hence, Billed Right’s advanced RCM model revolves around personalized service in today’s corporate world, while still cutting costs and improving both patient care and practice revenue. No matter what challenges physicians face, we never waiver from our goal to be a strategic partner and promote practice growth.   


Contact Billed Right to learn more.