Contract and Closing the Deal - PDF by thz11885


Contract and Closing the Deal document sample

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      Contracting with Insurance                      Making the decision to contract with carriers
      Carriers and Medical                            Getting organized – doing your homework
      Groups – Deal or No Deal!                       How to start the contracting process
                                                      Pitching your services
                                                      Closing the deal
               Kathleen Wall, RD, CDE
                Facey Medical Group                   Actually getting clients referred
     CDA Healthcare Reimbursement Representative      Properly documenting visits

                                                     Making the Decision to Contract –
Managed Care Statistics
                                                     Fee for Service Payment
 Over 13 million Californians receive health          Fee for service payment requires less
 care through Managed Care Organizations.             paperwork.
 Over 50% of California’s healthcare delivered        Provides freedom and flexibility.
 by physicians working in Managed Care.               No contracts required.
 57% of Medicaid patients are serviced under          Patient pays for service out of pocket.
 managed Care MediCal.                                Requires more marketing efforts to attract
 Medicare Advantage (Managed Care) plans              clients.
 are increasing their marketing efforts.              Ability to set your own fees.
                                                      No lifetime maximum for visits.

Making the decision to Contract –                    Getting Organized - Do Your
with Carriers and Medical Groups.                    Homework
 Requires a contract for payment.                     Know the Medical Groups or IPA’s.
 Potential for a greater pool of clients.             Learn the terminology.
 Easier access to clients medical records.            Find the contracting contact person.
 Must establish negotiated fees for service.          Establish your niche!
 Bound to policies established by carriers.           Network, network, network!
 May need prior authorization for visits.             Set up standardized paperwork forms.
 Potential for limited number of follow up visits.    Set your fees.
Knowing Medical Groups and IPA’s                                     Knowing Medical Groups and IPA’s

 Medical Groups – a group of physicians that                          Gather information by visiting their website
 contract with a health plan to manage a                              and look at the structure of how many PCP’s
 patients health care. Use a Staff Model of                           and specialty areas are within the group.
 “internal providers” and either “internal or                         How many patients do they service.
 external” specialty practices.                                       What type of preventative medicine services
 Individual Practice Association (IPA) –                              they provide.
 individual or small group of physicians who                          Who is the Medical Director or better yet find
 contract with a health plan to manage a                              out who is the Provider Relations or
 patients health care. Primarily “external”                           Contracting Person.
 providers and specialty areas only.

                                                                     Start the Process -
Learn the Terminology
                                                                     Pitching your Services.
 Capitation System – A specific dollar amount that is allotted to     Write a Letter of Intent to contract.
 the Managed Care Group to cover the cost of all health care
 delivered to a patient in a designated period of time (usually       Keep the Letter of Intent simple and to the
 Gatekeeper – the term used for a provider that arranges,             point.
 approves and coordinates medical care of an individual.
 Case Management – a process used to manage and meet
                                                                      Sell yourself similar to sending your resume.
 specific health care needs to produce a favorable outcome in a
 cost affective manner.
                                                                      Be specific about the services you can
 Pay for Performance (P4P) – an incentive based strategy by           provide to the carrier or Medical group.
 which providers are paid more for improving their patients health
 outcomes.                                                            Market your expertise – differentiate yourself
 Hierarchical Category Codes (HCC) – similar to ICD9 codes            from other dietitians!
 but are used by Medicare Advantage plans for increased
 payment for providers assessing and treating chronic diseases        Show the cost effectiveness of MNT services.
 and conditions.
                                                                      Speak their language!

                                                                     Getting the Contract – Closing the
Getting the Contract
 The contract sent by health plan or Medical                          Review the contract carefully before signing.
 group will contain many components.                                  Refer to an Attorney if necessary.
 Outlines rates for services and billable CPT
 codes with payment terms – usually 85% of                            Be willing to strike or negotiate.
 Medicare fee schedule or lower.                                      Certain terms or payment issues may need to
 States how referrals are made and                                    be clarified.
 processed.                                                           Focus on the main contract agreements.
 May provide number of allowable visits per                           Don’t be afraid to walk away if not satisfied
 client.                                                              with their terms of the contract.
 Uses standard or generic language.
Getting Clients Referred for
                                                  Properly Documenting Visits.
 Request a meeting with RN Case Managers,          Consult note should include no more than 3
 Medical Director or Referring Providers to        goals of MNT at a time.
 present your offered services.                    Number of potential visits needed to
 Prepare brochures and marketing pieces that       accomplish the set goals.
 clearly describe the services you can provide.    All pertaining nutritional conditions treated
                                                   during the visit.
 Offer to set up a breakfast or lunch meeting
                                                   Use the Nutrition Care Process Model for
 with referring parties.                           documenting.
 Stay in contact with provider relations or the    Use a CMS 1500 Form or find out if you can
 contracting person.                               electronically submit notes and claims .

Follow up Documentation                           Resources/References
 Establish what percentage of initial goals        “ADA Guide to Private Practice” – Ann Litt, MS, RD and
                                                   Faye Berger Mitchell, RD.
 were achieved by the patient.            – Advocacy and the Profession – MNT
 How many more visits are needed to                link.
 accomplish the goals.                    – Public Policy Council site
                                                   “Understanding and negotiating access contracts with
 Any changes in medical condition of nutrition     insurers and complementary networks” Mary Albarado,
 treatment plan.                                   MS, RD, FADA. JADA. Volume 102, Issue 2, pgs 187-
 Request further authorizations for additional     “Tips for contract negotiations and establishing MNT
 visits only when set goals were not achieved.     rates”, Esther Myers, Pam Michaels, Karen Duester.
                                                   JADA. Volume 101 Issue 6, pgs.624-626.
                                          – California Association of Physician
                                                   Groups. Resources information about Medical Groups and
                                                   IPA’s in CA.

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