Gastroenterology Coding Alert

Hint: Persistence is crucial.

As we sprint toward 2023, now might be time to run some diagnostics on your practice to see if there are some areas that can be improved before the new year. In a recent HEALTHCON session, speaker Marcia Brauchler, MPH, FACMPE, CPC, COC, CPC-I, CPCQ, shared how you can successfully negotiate payer contracts, and we think the information is just what the doctor ordered.

If you’re interested in potentially increasing rates or otherwise improving on the terms of some of your payer contracts, you’ve come to the right place.

Stay the Course

Brauchler described what she called a “pretty typical example” of the effort it took for a practice to succeed in raising their rates with insurance carriers: A practice representative requested a contract improvement with a payer on April 6, made 23 different points of contact over the next four months, and by August 15, successfully negotiated a +7 percent increase for year 1 and a +5 percent increase for year 2. “You basically have to take no for an answer, or not take no for an answer, 22 times, because in this case, it took 23 times to get to a yes to get to something assignable to acceptable for the practice,” Brauchler said.

Although a rate increase may be the best your practice can hope for, you may not be successful; but, at the very least, going through this process will help you prioritize organization and set you up for other forms of success. “Even if you’re unable to get a rate increase, which, frankly, should be fairly reasonable — you should expect to get a rate increase. But if you’re unable to get a rate increase, there are still some intangible benefits that make renegotiating your payer contracts or tackling your payer contracts something of value for your time and your position at the practice,” Brauchler said.

Aim to Capture Benefits Beyond Just Rate Increases

You may have not known the fee schedule for a particular carrier for your practice, but persistence could lead you to getting that information in black and white, including what your reimbursement should be per procedure code. Or you could negotiate to get your contracts to be mutual written amendment only, instead of unilaterally amended by notice of material change. Another possibility is making your contracts have a 90-day without-cause term, instead of longer periods, which would allow you more flexibility in getting out of a contract.

Also look for potential to add in cost-of-living adjustments for contracts instead of agreeing to stick to an evergreen rate. Check in about the geographic pricing available for your practice — and make sure it’s correct — especially if you’re in a state or area with a metropolitan area that may be a lot wealthier than the surrounding rural rates.

Check In With all Payers

Brauchler explained that the bulk of reimbursement for a practice is often earned from maybe four carriers, but, often, one carrier represents the majority of revenue. It may seem like a good idea to put most of your effort toward negotiating with that main payer but focusing all your effort on one carrier alone or one at a time may not be your best bet.

“It helps to have all four of these things in the queue at the same time because you’re going to have maybe 23 different contacts with each payer; and doing them all, at the same time, you can try to do a little bit every week while waiting for those 23 contacts to occur,” she explained.

“If you’re just following up with one payer at a time, it’s going to be a really long, slow, drudge of a negotiation, so I recommend all the economies of scale. Do all of your major carrier negotiations at the same time,” she said.

Also, sometimes the only way to get a payer’s attention is to actually terminate the contract, which commonly means 90 days until you are out of network. “Of course you have to be in the position financially of being able to be out of network if the payer doesn’t respond. In many cases though, this will elicit a better offer, sometimes before, but sometimes after the contract lapses,” says Glenn D. Littenberg, MD, MACP, FASGE, AGAF, a gastroenterologist and former CPT^® Editorial Panel member in Pasadena, California.

Notice Times Have Changed

In the past couple of decades, the landscape of commercial carriers has changed a lot, with companies aggregating and purchasing one another. This trend has affected competition, and thus fee schedules — and almost never at rates that benefit practices.

Some carriers are particularly big cash cows — for private equity firms, not the patients or providers whose lives are more directly affected by the cashflow.

For example, if you have a contract with MultiPlan, Brauchler recommends focusing some cleanup efforts there. (You can find more information on how MultiPlan contracts at one rate but gets paid at a huge markup by going to www.wsj.com/articles/ BL-MBB-49396.) But Brauchler says many practices she works with end up terminating their contracts with MultiPlan after some investigation of their agreements with the carrier.

You should feel confident that you can advocate for yourself and your practice, and getting a clear picture of exactly what’s going on is crucial to those efforts.

Remember Some Things Are Nonnegotiable

Mandated fee schedules, such as Medicare’s, can’t be changed, meaning you can’t adjust what Medicare is paying your practice. While some people have had success advocating for changes with Medicaid, any changes made would affect everyone in the state using a particular code, Brauchler explained.

However, you should check in on TRICARE as a matter of housekeeping if you provide services to any military patients, because changes that went into effect in 2018 may mean you’re earning less than what you’re owed. Aim for achieving the same pay rate from TRICARE as you do from Medicare in your state.