Contracts: Create a Health Plan Contact Database
By Marcia Brauchler, MPH, CPC, CPC-H, CPC-I, CPHQ
Imagine trying to renegotiate your payer agreements by calling health plans’ toll-free phone numbers. In my experience, calling a provider relations department is not helpful with regard to contract-related issues because of high turnover and limited authority. Unfortunately it’s not always easy to know who the best person is at each health plan to handle your contract inquiries. Certainly you don’t want correspondence with a health plan to be generic, such as “To Whom It May Concern.” The solution is to create a database of payer contacts.
Look for Contacts with Authority
Ideally, you want your payer contact to be the representative for your geographic area and someone with enough authority to make decisions—the more authority, the better. Generally, don’t approach a medical director unless it’s for a very specific reason. In my consulting firm, we create an overview for our clients, listing their payers alphabetically and with the data shown in Table 1. We call this an “Alpha Payer Contact List.”
Table 1: Sample Alpha Payer Contact List
Phone and Fax
Delta Workers Comp
Who Are You Going to Call?
There are several methods to help you identify the best payer contacts:
· Look at who signed your existing agreement for the health plan. Even if that person is no longer there, you might get transferred to his or her replacement.
· Look at recent correspondence from the health plan, such as a cover letter announcing a change in Utilization Management Policies.
· Look at the “Notice” section of your existing agreement and contact the building address using the white pages.
· If you have a number for anyone in the building, hit “0” for operator or use the name directory to dial one digit off the last number until you get someone to answer the phone and direct you to the appropriate contract representative. As a general rule, network management or contract representatives are better equipped to discuss your payer contract than personnel in provider services or provider relations.
· For-profit health plans have Investor Relations departments with contact information readily accessible on their website. They may be kind enough to redirect your call to the correct department.
· State Divisions of Insurance have public health maintenance organization (HMO) quarterly filings, which contain upper-level management contact information for the health plan.
If you need just one issue addressed (e.g., a supply you provide is not being reimbursed at invoice cost), this technique will narrow the focus to something attainable to get the right name of the contracting person.
· If you have a contact you work with for credentialing, he or she may be able to direct you to the best network management or contract representative in your area.
In addition to these tips, you can also try contacting hospitals where the physicians have privileges (the bigger the hospital or hospital system the better) and ask to speak with the hospital’s managed care contractor. Hospitals generally have a full-time person responsible for payer contracts and have a robust database.
Be aware that most health plans have entirely different contracting departments for hospital/facilities than for physicians. If you ask the managed care contractor at a hospital for their list of payer contacts, however, they will probably be more than happy to give it to you. Your physician referrals to the hospital are invaluable and the hospital wants to see private practice physicians stay in business.
Make Contact and Complete the List
When you get the list, call the payer contacts using the name of the hospital’s managed care contractor (with whom the health plan has a relationship) as your source. This might go something like this:
· “I’m ______ and I got your name and number from ______ at _____ Hospital.”
This will get the attention of the health plan’s managed care person, who will be happy to help you because he or she will want to maintain a great relationship with the hospital.
· “I’m calling on behalf of a physicians’ office. I know you do facility contracting. Can you please tell me who within [PAYER NAME] handles the physician contracts for our area?”
Then obtain the information to complete your “Alpha Payer Contact List” for that payer.
If, during your investigation, you speak to or email the payer contact directly, just state that you are new to the practice or position, and are reviewing your agreements on file (remember the importance of data gathering, which we discussed in the article, “The Big Picture of Contract Negotiations,” (pages 29-32, October 2012, Coding Edge).
Helpful Tidbits for Success
Here are additional tips to help you create an Alpha Payer Contact List:
· Never start the conversation stating that you are interested in negotiations. It turns off the payer contact every time.
· Remember: You are only confirming your current contracts. The payer contact should be eager to provide this information because, at this stage, you aren’t making them do any other work (e.g., a renegotiation).
· Reference your agreement exactly how the health plan refers to it (for example, “Specialist Provider Agreement”) so it’s easier to reference down the road in the context unique to that payer.
· Make sure to confirm/document the contact’s gender so in future correspondence you’ll know how to properly address the person.
When you complete your “Alpha Payer Contact List,” the negotiation process can begin. The next time you’ll probably approach the payer contact is with a Health Plan Proposal Letter. (We will go more into the content of a Health Plan Proposal Letter in Part 4 of this series on contracts.) All of this up-front work will ensure that this important letter is not stuck under a pile of paperwork; and that, from the get-go, you are working with the best payer contacts at your contracted health plans.
Marcia Brauchler, MPH, CPC, CPC-H, CPC-I, CPHQ, is the founder and president of Physicians’ Ally, Inc., a health care consulting firm and concierge billing company for specialty physician practices. She works with physicians on managed care contracts, reimbursement, and practice administration. Ms. Brauchler’s experience includes hospital, health plan, and independent practice association administration. Her firm sells updated HIPAA policies and procedures and online staff training. Ms. Brauchler is a published researcher and a frequent public speaker.