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Do you have questions about managed care and other contracted reimbursement issues?
Here's your one stop resources for any questions you want to ask.
Dr Maria Todd, author of the best selling managed care contracting handbook will answer!
About Your Expert
Trusted by more than 4500 healthcare organizations, facilities, physicians, and ancillary providers in the USA and 116 countries, Dr Maria Todd is frequently hired to help with contract and negotiation strategy, payer innovation partnerships, pricing logic, and shared risk arrangements including capitation, bundled price surgery, physical and occupational therapies, rehab services, and diagnostic testing bundles.
She's been a director of contracting for several health plans (HMOs & PPOs), IPAs, PHOs, MSOs, ACOs, medical groups, ASCs. She leverages her OR nursing experience, hospital and clinic administrator hands-on experience, and health law paralegal and mediator work experience and training.
She's been the expert on managed care contract analysis and negotiation and a leading trainer for HFMA and other healthcare industry professional development associations in the USA and abroad.
WHAT PROBLEM DO YOU NEED HELP WITH TODAY?
Whether the problem is an unfair reimbursement rate, inflexibility by payer representatives, moving past a stalemate, payer representative ghosting, or getting payer buy-in on an innovative product or service, contracting directly with self-insured employers and their TPAs, or evaluating a bundled price proposal – Maria can probably help you.
In most cases, these problems are not unique, personal, or limited to your organization. Others have had similar situations and Maria has been able to come up with workarounds, solutions or reassurance that they were on the right pathway.
Maria will schedule a time to take your call so you can explain what’s going on or what has you stuck. She’ll tell you if she can help, or if she believes another expert with whom she works from time to time can offer a better solution.
If you decide to work with her, she’ll quote a price – by the hour, by the assignment, or for training via web-based conference or at your location.
What you’ll find on this Ask the Expert section of her website are answers she’s provided to others in a similar situation to yours in the past. Reading her responses will provide you inspiration, hope, and tips and pointers you might not have considered.
From there, you can read more tips, research the topic further on your own, decide you’d like to learn more about working with her on a detailed solution, or get a recommendation for what to try next. Or, alternatively, you can ask Maria if she has time on her schedule to meet your deadline to handle the matter for you. The choice is yours.
But first, read on to learn what others have asked Maria Todd and the answers she’s provided.
EMPLOYMENT, TRAINING, WORKING LIFE
Where can I find managed care training, educational seminars, webinars, master classes or conferences for 2020?
The majority of managed care training, seminars and conferences in 2020 that are open to anyone in the industry will be held in St George, Utah.
What is the average salary for a managed care analyst and negotiator in an urban setting?
The range tends to be about $90,000 – $125,000 in a urban setting and between $55,000 and $70,000 in a rural setting where the major health plans are active.
Do many employed managed care contract analysts work remotely?
While some employed analysts may work a percentage of their time remotely, most quickly realize they need to be present at their employer’s location to answer questions, troubleshoot payment and contract interpretation problems, and be accessible to revenue management team and managers, administrators and medical staff during operating hours.
What will happen to managed care contracting jobs under Medicare for All?
It’s premature to answer a question about a concept that is not yet approved, enacted, or the rule of law. Until ERISA is repealed or otherwise modified and also the Taft-Hartley Act, you’ll still find unions and self-funded employers with health plans organized under ERISA, as well as church plans that may still be able to run their own plan and enjoy pre-emption of certain rules. For now, focus on polishing your ERISA skills because the role may transition to contracting on behalf of providers directly with employers’ and union plans.
GETTING MANAGED CARE CONTRACTS
I am a new physician in private practice. How can I get payer contracts?
First, determine which payers operate in your county and/or your region. Next, contact provider relations to discover their contracting criteria and need for your services. Next, create a contracts strategy to prioritize which contracts with which payers, what you want, what you don’t want, and why. In your strategy, include solutions to the problems they have and how you might help them arrive at a solution with what you do that’s different from the rest of their providers. Then prepare cover letters that address each payer’s needs and what you offer to help solve for that need and that you’d like to discuss the possibility of joining their network.
Realize that there may be silent forces working against you in your area. Someone may have an exclusive deal carved out, someone may have disparaged you, your social media feedback and stars may be less than wonderful, or you may lack privileges at the facilities they are contracted with – or other market forces which you may lack influence or control. If you find some nasty or shady deals, contact an antitrust attorney for guidance.
MANAGED CARE CONTRACT TERMINATION
A major national payer has terminated our 10-location, senior-centric practice from its MA plan without proper notice, for no cause, and is now telling our patients to change doctors because we refused to sign their new contract. What can we do?
Well first, call your attorney! You have a conflict if there is a “because” to the public and a “termination without cause” to you. There could be a defamation issue as well as the conflict.
“Without proper notice” is a procedural issue that your attorney will sort out.
” Your attorney may need to get a court-ordered action to “stay” the termination effective date to benefit your patients, and a “cease and desist” on telling patients untruthful statements to interfere in the doctor-patient relationship and divert patients (their assets, by the way) to a different provider, until the matter is sorted out.
MANAGED CARE CONTRACT STRATEGY
Is the trend I am beginning to see of direct-with-employer contracts really a “thing”?
Yes, and many of them are seeking out providers who will share risk, give full transparent line item pricing up front, delegated credentialing and bundled pricing. You’ll also see them contract through some of the TPAs in the nation. To function in this niche, you’ll need to have a strong grasp of ERISA and Taft Hartley Act, workers comp, Medicare as a Secondary Payer and coordination of benefits as well as shared risk contracting, pay for performance, delegated credentialing, pricing integrity and healthcare costing. You’ll also need to know about carve outs and alternative pricing programs. The only courses I’ve encountered on this contracting strategy for providers are mine, scheduled in St George, Utah in 2020. Hope you can join us!
Should I be afraid to drop a contract that rarely sends us any business?
That’s a far more challenging question that appears on its face. One must first know how the marketplace locally is divided, if there are any mergers or acquisitions planned, why they aren’t sending business, what the past 36 month trends looked like for revenue, utilization and profitability and collections on the self-pay side of the financial responsibility.
Is there a published set of tips or business rules I should be using to frame my negotiation strategy and contracts strategy?
Yes, it exists in my Managed Care Contracting Handbook, 2nd edition. It will be included in the 3rd edition as well. I’ve not seen others. It is included as a bonus in my Managed Care Master Class titled, Analyzing and Negotiating Managed Care Agreements. But having the list is only part of the solution. Your organization must prioritize the list to give you guidance as to what to concede in trade for something higher on the list.
And if you are contracting on behalf of an IPA or ACO or PHO or MSO under the “messenger model” you’ll need each independent physician to also prioritize and keep track of their priorities when negotiating on their behalf.
Is there an easier way to build fully-inclusive bundled surgery case rates? I’m struggling.
Yes, it exists in my Managed Care Contracting Handbook, 2nd edition. It will be included in the 3rd edition as well. I’ve also developed a software that is in beta test phase that is very easy to use, cloud based, and fill in the blank. But using the software is only part of the solution. The one prerequisite: You must know your fully loaded costs to have data to enter into the software. I’ll bet that’s what you are struggling with. Also, if you don’t have any clinical knowledge of the surgical procedures, you’ll need assistance from a colleague with that insight so that each price is actually a number that covers a defined episode of care, start to finish.
MANAGED CARE PAYER AUDITS
A major national payer called stating she’d be here in an hour to do some records/bill audits. Is that allowed?
What does your contract say? Did the contract specify advance written notice with a minimum advance time frame specified? There’s a lot you can do to minimize the cost and hassle associated with this. I cover these options in depth in my Managed Care Master Class titled, Analyzing and Negotiating Managed Care Agreements. Hope you can join us for class this year!
MANAGED CARE LANGUAGE ANALYSIS
A contract I was assigned to review uses the phrase “reasonable commercial efforts” in places where I used to see “best efforts” Is there a difference?
Yes, this is a point I emphasize in my Managed Care Master Class titled, Analyzing and Negotiating Managed Care Agreements. In best efforts, one is expected to go to greater lengths to comply to some unquantified superlative. The term reasonable commercial efforts is less demanding, in that commercially reasonable efforts refer to efforts which use a standard of reasonableness defined by what a similar person would do as judged by the standards of the relevant capabilities of a healthcare organization of its type.
Where can I find a thorough Managed Care Contract Checklist?
This is an item I provide as a bonus in my Managed Care Master Class titled, Analyzing and Negotiating Managed Care Agreements. There’s also a 26-page checklist in the back of the 2nd edition of the Managed Care Contracting Handbook, as well. I also have several others depending on the type of provider and payer negotiating the deal.
Where can I find a good and fair Managed Care Contract Template?
I can provide a template but first, it must be determined if the payer will consider your draft agreement. I discuss this at length in my Managed Care Master Class titled, Analyzing and Negotiating Managed Care Agreements. I have several templates to share with clients depending on the type of provider and payer negotiating the deal.
MANAGED CARE PAYMENT PROBLEMS
A major national payer is paying me less than the numbers agreed to in the contract we executed. Less than Medicare, in fact! I call, I write, and they don’t respond.
Yes, this is a lesson I focus on in my Managed Care Master Class titled, Analyzing and Negotiating Managed Care Agreements. First, are you writing to the named party in the notice section? The so-named person is required to respond. If you aren’t writing to the appropriate person, there is no duty to transfer your call or letter to the so named party. Follow the contract you executed.
Second, if you allowed any “lesser of” language to exist in your contract, that could be one problem. This could be the reason why, but I can’t be sure without research.
Third, it could be a problem with a system load in their adjudication system. It could be a problem with a payer ID conflict in their system.
If they refuse to respond, after you’ve noticed the named party or titled role and given about 20 days to respond, you can call upon the State Insurance Commissioner and ask for a copy of their past Market Conduct reports, a copy of the “Jurat” page of their annual filing and use that information to work up the chain of command to someone responsible for contract compliance.
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