Objectives 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 Email: firstname.lastname@example.org Resources 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 yearly). 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 Deal. 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. Service 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. www.eatright.org – Advocacy and the Profession – MNT How many more visits are needed to link. accomplish the goals. www.dietitian.org – 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- 189. 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. www.CAPG.org – California Association of Physician Groups. Resources information about Medical Groups and IPA’s in CA.
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