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Avoid Payer Contract Horrors: Know When to Call Your Attorney

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Avoid Payer Contract Horrors: Know When to Call Your Attorney

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managed care contracts

Whether you’re negotiating managed care contracts for the first time in your career or you’re a seasoned pro, one thing is certain: you can’t afford to make a mistake.

Reimbursement from managed care insurers is likely to make up the bulk of your practice’s income, so it’s critical that you understand exactly what language to include in your contracts and which details you should focus most of your attention reviewing.

It probably takes you weeks to properly scrutinize managed care contracts, but if you don’t review them closely enough, you could be seeing patients at a fraction of what you’d prefer to collect.

Following are a few key ways healthcare attorneys can help you navigate your managed care contracts, eliminate errors, and bring in maximum pay from insurers.

Set Goals for Managed Care Contracts Ahead of Time

You may think you know what your practice wants and needs from your managed care contracts, but sometimes your payers write contracts to benefit themselves, and they might slip terms into the contract that are easy to miss. A healthcare attorney can help you analyze where you need better contract terms that will allow you to collect higher payments, ensure that you receive reimbursements faster, and figure out which of your current contract provisions are hurting your practice.

After analyzing your current situation, your needs (both financial and professional), and details about your practice, the healthcare attorney can help you set goals up front so you’ll be in a better negotiating position. By understanding your goals, you’ll know what the “must-haves” are in your managed care contracts, as well as the provisions that are just “nice to have.”

Negotiate Higher Payments

In many cases, insurers that the terms of the managed care contracts they’ve presented to you are set in stone, and that you must accept the provisions as they’re laid out in the initial draft. However, this is merely an intimidation tactic that some payers use to get you to sign right away. This has been happening for decades, and it still stands true today.

In reality, you have significant control over the terms of your managed care contracts, including how much your insurers will pay you for the services you provide. A qualified healthcare attorney can help you create a market and provider assessment that shows payers why you deserve more money than what’s laid out in the contract.

Here’s what it is: A market and provider assessment allows payers to see the average patient demographics in your area, referral patterns, the conditions you see most frequently, and the codes you report together most often. After reviewing this, your insurer will better understand how the terms of the contract they’re proposing won’t work for your practice. A healthcare attorney can help you put together these assessments to help payers see exactly why you deserve more money.

To create this, your attorney will work with you on gathering the expenses you incur simply by running your practice, including overhead, supplies, staff members, and more. In some cases, healthcare attorneys allow providers and practice managers to realize that their managed care contracts are actually causing them to lose money. The attorney can then help you renegotiate your fee schedule and terms to allow you to bring in more income.

Untangle Confusing Terms

Some managed care contracts include confusing, legal-laden terms that can cost you when it comes time to collect reimbursement. For instance, certain payers are known for including lingo referring to matching the lowest provided prices. This may seem harmless to you, but an attorney would recognize the pitfalls of this. Particularly if it ends up requiring your practice to college managed care rates that match Medicaid rates, which are often much lower than you’d collect from private payers

Because this type of verbiage is frequently buried in managed care contracts, you could easily miss it or interpret it incorrectly, but a healthcare attorney would zero in on it, saving you thousands down the line by catching it and correcting it before you sign on the dotted line.

Ensure Timely Payments

Financial terms are important, but they aren’t the only factors a healthcare attorney can help you perfect as part of the managed care contracts process. Another essential step is confirming timelines, and lawyers are adept at recognizing terms that will hurt your practice. Following are just a few of the timeliness provisions that your healthcare attorney can scrutinize with a fine-toothed comb:

  • The amount of time that the insurer has to pay you after receiving your claim
  • Specifics about interest you can collect if the payer reimburses you after the payment period
  • How long after the date of service you have to submit your claims
  • Timelines for modifying contract provisions in the future
  • Advance notice you must provide if you decide to cancel the contract

Although managed care organizations will tell you that these terms aren’t negotiable, a skilled healthcare attorney will show you that they are. It may take some time to negotiate the terms in your favor, but that’s why engaging legal help is so important.

Pinpoint When to Walk

If you’ve spent hundreds of hours trying to make sense of your managed care contracts, you’re invested in the process — so much that you may be inspired to just sign the contracts, even if the terms aren’t exactly what you wanted. Working with an attorney can help you evaluate when you’re better off walking away. This can be hard to digest, but sometimes it’s the best option when you simply aren’t able to negotiate terms that are beneficial for your practice.

Negotiating your managed care contracts properly is critical to ensuring that revenue keeps flowing into your practice. To get more details about how to know when it’s time to involve legal counsel in your contract reviews, check out the online training session, Managed Care Contracts: Proven Language to Get Paid More. You’ll learn how to speak the payer’s language, negotiate better rates, and remove harmful clauses that could result in financial penalties. Sign up today!


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