How To Negotiate a Better Insurance Reimbursement Contract?

​With midwifery care on the rise in the United States, people are starting to hear about midwives and home birth. Increasing labor cost, malpractice insurance, and midwifery supplies, private midwifery practices need to identify areas where income can be increased to ensure the financial stability of your midwifery business while providing high-quality midwifery care. While you can’t always increase revenue through increasing service costs, you may be able to find more money through negotiating or re-negotiating payor contracts with your biggest insurers.
The best way for negotiating fees with health care plans is to have more leverage. Below are some tips and tools on how to effectively negotiate.

1. “Readiness is everything and benchmarking will provide the quality and efficiency needed to engage in strategic planning.”
2. Analyze strengths and weaknesses
3. Maintain data about utilization, revenue, and expenses
4. Measure quality
5. Regularly survey patient satisfaction
6. Rank referring midwives by frequency and type of referrals
7. Keep abreast of the industry and learn from others
8. “Analyze the fee schedule of a payer will help with calculating the weighted average reimbursement payment.”
9. Create a spreadsheet listing every CPT code and the number of times it was billed for that payer
10. Multiply the use of each code by the proposed payment of the payer
11. Add together all of these products and divide by the total frequency of all codes to determine the weighted average payment for that payer.
12. “Monitoring contracts provides a systematic way of allowing contracts to go unchanged for several years.”
13. Know when each of your contracts expires and how much notice you must give to make changes
14. Analyze the contract and determine whether changes are needed
15. Caution physicians in your practice against signing any paperwork they receive (e.g., addressing rates, charges, reimbursement, or network participation)
16. “Determining your position is important in order to determine what percentage of your business the payer represents.”
17. Know your alternatives including BATNA
18. Monitor your payer mix year to year
19. Set a bargaining range that includes an optimum, minimum, and target goal.
    • Optimum is the starting point, the terms you consider ideal
    • Minimum is the point that must be met for you to sign
    • Target is the point you would like to end up after negotiation
20. “When should you walk away? When you are receiving low contract rates.”
21. Do not accept poor contract terms
22. Decide on your bottom line ahead of time after weighing all the factors
23. “Negotiating the contract is important so that you are meeting your market needs.”
24. Contact the plan representative and set a face-to-face meeting
25. Present well-organized and clear data
26. Present requests for changes based on your optimum objective before new terms are offered
27. Basic negotiating principle is that you are negotiating a relationship, not a transaction
28. Understand the goals of the other party, be polite and listen carefully to what the other party has to say
29. “Fees are not the only items to negotiate there are other contractual elements to consider.”
30. Authorization process for treatment
31. Period specified for submitting claims
32. Period allowed to appeal a denied claim
33. Requirements regarding use of oral or injectable drugs
34. Time specified for timely payment and interest paid for late payment
35. Process for adding new service lines or adding new physicians to the plan
36. Period required for providing notice of modification proposals
37. Cancellation clause, including the advance notice required

 
Negotiation is crucial especially with the fact that insurance provider may have a little upper hand in the negotiation process as they have the money to sustain your practice. While making sure you get the best agreement, always have your legal team on the side. One important way to win a negotiation is that you show them you know what you are doing, by having the right people on your side.

References
Gesme, D. H., & Wiseman, M. (2010, July). How to negotiate with Health Care Plans. Journal of oncology practice. Retrieved June 17, 2022, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2900878/
Tips for doctors on how to negotiate reimbursement rates with health care plans. Clinic Service. (n.d.). Retrieved June 17, 2022, from https://clinicservice.com/tips-doctors-how-negotiate-reimbursement-rates-health-care-plans/