Maria Todd has been consulting to integrated physician groups (IPAs, PHOs, MSOs, and ACOs) helping them plan, launch, operate and contract with third-party payers since 1989.
INTEGRATED PHYSICIAN GROUP (IPAs, PHOs, MSOs, and ACOs) DEVELOPMENT
Maria Todd brings clinical, administrative, insurance contracting, and dispute mediation experience to help your integrated physician group practice or physician hospital organization compete and negotiate contracts with third party payers.
Since 1989, she's helped over 400 integrated physician groups (IPAs, PHOs, MSOs, and ACOs) in the USA develop their network, infrastructure, contracting strategy, and break through negotiation stalemates and settle payer/provider disputes. In 2010, she was awarded a trademark registration for the term "Globally Integrated Health Delivery System®" to mark a new innovation in cross-border integrated health delivery. She is also the author of two of the best-selling, internationally published handbooks on the topic of developing integrated physician groups (IPAs, PHOs, MSOs, and ACOs).
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How Maria Can Help Integrated Physician Groups (IPAs, PHOs, MSOs, and ACOs) with network development, operations, and competition for better third-party contracts
Find Loopholes and Risks
Nobody likes being taken advantage of. Healthcare providers of all kinds take on professional liability risks at every patient encounter. Continue
Maria helps integrated physician groups (IPAs, PHOs, MSOs, and ACOs) to negotiate better group contracts with insurers, health plans and self-funded employers and labor unions on behalf of their network participants. Call her to explain your situation and learn how she can help your group meet its objectives.
Differentiate Your Group
Physicians often interpret "branding" to be about logos, and slogans, and naming. These are actually the outputs of branding creation. Continue
In healthcare, developing a strong brand for your integrated physician group helps you connect with health plans, self-funded employers, labor unions and healthcare purchasing coalitions at an emotional level. In turn, they feel good about contracting and negotiating with you which usually leads to higher (about 14% on average) reimbursement that what your unbranded competitors can achieve.
Integrated physician groups without an established brand compete for contracts as a commodity. Payers and patients believe that the network is easily substituted or replaced. Instead of leveraging your brand to win higher paying contracts, insurers, employers and labor unions view your integrated physician group as a commodity and you put yourself at the mercy of market prices, and their boilerplate contracts with little leverage to negotiate a better deal.
End the FrustrationDo you need an outsider's perspective on the rates you are being offered for your integrated physician group's services? Continue
Lockouts and TerminationsThe trend towards narrow networks are giving rise to provider lockouts and terminations like never before. Continue
Mediation & ArbitrationDoes your contract prohibit litigation of troublesome payer/provider disputes? Before you sign your contracts, Continue
Case Rate PricingCase rate pricing in healthcare reimbursement contracts is risky business. So often, the payer brings offers that are incomplete, or Continue
Managed Care Training
Training & CoachingMaria Todd has been teaching managed care contracting classes for HFMA, MGMA, AICPA, and hundreds of professional development associations.Continue
Quick ReviewsPayer market entrances and exits, consolidations, mergers and acquisitions often mean that a healthcare provider will face Continue
TRAINING ON SHARED RISK & ECONOMIC INTEGRATION FOR INTEGRATED PHYSICIAN GROUPS
Many integrated physician groups have jumped into contracting with third-party payers without the appropriate level of "economic integration" and lack adequate training and guidance necessary to legally achieve their goals and objectives. These decisions have led to painful and costly federal investigations and prosecutorial action for both the physicians and their consultants.
Integrated physician groups, (IPAs, PHOs, MSOs, and ACOs) are usually comprised of one or more hospitals and numerous independent and employed physicians with privileges at those hospitals. Like any combination of competitors, physician networks run the risk of violating the antitrust laws. Agreements on price among competitors are generally illegal under the antitrust laws and punishable as a felony. Agreements on price among legitimate joint ventures usually are not. Continue
Is your organization breaking the law?
It's been more than a decade since the Supreme Court ruled that a physician "foundation" establishing the maximum prices for certain physician services was "per se" illegal -- illegal on its face without any further inquiry. In that same case, though, the Supreme Court hinted that physicians could associate as a "joint venture." To qualify as a joint venture, individuals who would otherwise be competing must share the risk of profits and losses and must integrate to provide a new product to the market. The lesson is that no matter what a network is called (IPA, PHO, MSO, ACO, Clinic Without Walls, etc.), if it amounts to otherwise competing physicians agreeing on price without sharing economic risk, it may well be a violation of the antitrust laws.
In 1996, the Federal Trade Commission set forth the analytical framework for evaluating these organizations and other multiprovider arrangements. But that was more than 20 years ago and most newly formed IPAs, PHOs, MSOs and ACOS and even physician group practices made up of employed physicians augmented by independent contractor providers have no clue that they are one phone call or email away from a legal nightmare. All it takes is for your competitor who believes you are exerting market power to an unfair competitive advantage (or the health plan with which you've reached a stalemate during negotiations) to send an email or place a call to the USDOJ or FTC and your problems begin - even if you are innocent! In addition, many third-party payer agreements transfer financial risk to multiprovider networks that can drive the network straight to insolvency in a matter of a few months in the absence of excess loss insurance ("reinsurance").
Experts in this domain are rare
Maria Todd has been working with multiprovider organizations and contracting or guiding the negotiations for more than 400 of these integrated physician entities for more than 25 years with a spotlessly clean record. Most of her consulting contemporaries with years of experience have retired leaving the newly formed integrated physician groups with few experts to call for assistance. Consultants have been named in enforcement actions because of their involvement organizing these groups for the purpose of engaging in collective contract negotiations with health insurance firms and other third-party payers. When integrated physician groups attempt to use market power to negotiate higher prices or eliminate incentives to reduce prices, the scrutiny begins. If the conclusion by the USDOJ and /or the FTC is that the negotiation by an integrated physician group without the necessary shared risk and economic integration would restrict the choice of health plans available to consumers, everything goes sideways.
When you work with a consultant who claims competence in managed care contract negotiations in the individual physician practice, integrated multiprovider network, or hospital setting, you cannot simply assume that they know how to negotiate on behalf of an integrated multiprovider network (IPA, PHO, MSO, or ACO). Maria is one of the few remaining veteran consultants with more than 25 years of experience. She's worked with some of the brightest legal experts in the nation. She is also trained as a mediator and has helped payer and providers arrive at mutually agreeable terms without litigation or expensive arbitration or antitrust violations, and has also served as an expert witness in a number of antitrust and other legal actions involving IPAs, PHOs, and MSOs.
What's at Stake?
If your group attempts to negotiate with payers and health plan sponsors without substantial financial ("economic") shared risk or other necessary integration among the competing physicians, your joint pricing activities or other negotiation tactics (refusal to deal, boycotting, etc.) can be challenged as per se violations that could result in settlements with the USDOJ and FTC with consent decrees or worse - criminal prosecution.
Maria Todd brings your IPA, PHO, MSO or ACO the experience, integrity, and practical expertise to negotiate under both economically integrated and messenger model networks of physicians and hospitals. If prospective clients reveal their inappropriate intentions and organizational objectives during their introductory discussion to request assistance with contracting and will not comply with the requirements, Maria will decline their invitation to work with them.
You must follow the rules and negotiate in compliance with FTC and USDOJ regulations and guidelines, because in most consent decrees, federal enforcers will prohibit the physicians (and their consultants) from ever participating in collective fees negotiations and other actions with third-party payers. In the past, they have also prohibited ("enjoined") the physicians involved in the consent decree restricting their joining, owning stock in, or operating as an integrated joint venture or in an integrated group practice ever again. Furthermore, in addition to government enforcement, the antitrust laws provide for private suits by parties injured in their business or property by wrongful conduct (including your competing IPAs, PHOs, ACOs and individuals who claim they suffered losses as a result of your actions). Successful plaintiffs automatically recover treble damages -- three dollars for every dollar of damages proven, plus reasonable attorneys' fees.
Arrange an Informative Training Webinar for Your Integrated Physician or Multiprovider Network
Training for your integrated physician group leadership and membership on this topic can be handled through a convenient training webinar in about an hour.
Many of Maria's clients schedule this training to satisfy two objectives: first, to teach the entire organization and lay the ground rules and expectations. Early in the planning stages of network development, they call on Maria Todd to explain what's involved in economic integration from the perspective of a disinterested, external, third party expert. This mitigates political disputes among the ranks. It also facilitates better decisions regarding the level of economic integration they will build into their organizational strategy. Second, they use the training session documentation to demonstrate an ilk of compliance. By documenting that the group made the effort to learn the rules, and then decided upon a business model and its related compliance requirements regarding contract negotiations, pricing, and shared risk, regulators may take this commitment to doing the right thing in the event an innocent mistake is made or an allegation by a competitor gives rise to scrutiny.
Call Maria to learn about availability and fees for this webinar. Maria has no objection to recording the webinar so that you have proof of what was covered, and can be stored as a podcast along with other documentation and the invoice in your compliance files.
Maria Offers a Complimentary 15-minute Introductory Call
Call or email Maria to schedule a brief discussion so you can explain your concern or situation and see if she can help.