Initiating Contract Discussions With Health Plans

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Initiating Contract Discussions With Health
Plans

• Presented by Lisa Park
• Healthcare Reimbursement Manager
• Virginia Department of Health
• lisa.park_at_vdh.virginia.gov

January 15, 2013
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Educate What do you do?

• Health plans often are not aware of the various
  medical services provided by local health
  departments.
• There may be a misconception that medical
  services at health departments are free.
• Plans may not think that its members are going to
  a health department for services, especially if
  they are not receiving any claims from you.
• It is helpful if you have data on the number of
  members you have seen with a particular plan.

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Sell Your Health Department

• You obviously have value as a provider, or plan
  members would not be coming to you.
• Ask yourself
• Why are members seeking services at your health
  department? Co-located with WIC, Social
  Services, on bus line?
• What do you offer that a private provider
  doesnt? One-stop shop, walk ins.

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How will a relationship with your health
department benefit the plan?

• In many cases, there is a health department in
  almost every city/county in the state-they will
  gain providers in every locality, often in
  underserved or rural areas in greatest need.
• Greater member access to preventive services
  and/or immunizations.
• Less out-of-pocket expenses for members-you will
  be able to submit claims for them.
• If you provide services to members and cannot
  submit claims for payment, the plan may be
  missing data on utilization of services that are
  critical in determining their national plan
  ranking.

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NCQAs Health Insurance Plan Rankings

• NCQA-National Committee for Quality Assurance
• A non-profit group that develops quality
  measures and accredits health insurance plans,
  doctors, and other organizations.
• Plans, including private, Medicaid, and Medicare
  plans, are scored annually on their quality of
  care, customer satisfaction, and commitment to
  improvement.
• The clinical quality measures used are prevention
  and treatment, which make up 60 of the plans
  overall score.

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NCQAs Health Insurance Plan Rankings, Contd.

• These clinical quality measures, a subset of
  HEDIS (Healthcare Effectiveness Data and
  Information Set), are obtained in large part
  through claims data. Plans use claims data in
  their quality improvement programs.
• Some clinical quality measures used in the
  rankings
• Well Child visits, childhood and adolescent
  immunization status, adult flu and pneumonia
  vaccine status, breast and cervical cancer
  screenings, Chlamydia screening in women, lead
  screening in children, smoking and tobacco use
  cessation, and a number of other services often
  provided at local health departments.

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Why Rankings Matter?

• Widely published and publicly available-rankings
  for 2012 were even published in Consumer Reports
  magazine.
• Employers, savvy consumers, state Medicaid
  agencies and Medicare take these ratings into
  consideration when selecting plans.
• The Patient Protection and Affordable Care Act
  (PPACA) requires any plan sold through a health
  insurance exchange to be NCQA accredited
  beginning in 2014. Accreditation counts for 15
  of a plans ranking.

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In Summary--Where do you fit in?

• Health department provider contractclaim
  submission for services that are likely part of
  NCQAs clinical quality measures
• Increased access to providers for members in
  rural or underserved areas
• Increased member access to preventive services or
  immunizations
• Reduced out-of-pocket costs for members and
  increased convenience by adding providers that
  they are already seeking services from
• Increased member satisfaction with plan (customer
  satisfaction is 25 of overall NCQA ranking)

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For More Information

• The 2012 NCQAs Health Insurance Plan Rankings,
  their methodology, a health plan report card by
  state, and a wealth of other information can be
  found at
• WWW.NCQA.ORG

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When you get a Contract

• Contracts should be reviewed by an attorney
  familiar with laws pertaining to your state or
  local government agencies.
• Many contracts contain similar language, so the
  same clauses contrary to state/local agency
  statute are often in the contracts of many
  carriers.
• Consider working with your legal counsel to
  develop a standard contract addendum that can be
  used to address common conflicts.

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Common Contract Provisions That May Conflict with
State or Local Law

• Requiring liability or malpractice coverage above
  what statute provides
• Requiring return of proprietary materials,
  including your contract, in the event of contract
  terminationthis may conflict with laws requiring
  governmental contracts to be kept for a specified
  period of time
• Requiring non-disclosure of contract or terms
  which may conflict with FOIA as it relates to
  governmental business
• Requiring the application of the law in any state
  other than your own in resolving contract
  disputes or enforcing the contract
• Automatically renewing or extending the contract

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Additional Provisions to Consider Negotiating

• Timely filing of claims-insist on no less than
  180 days
• No PCP referral required for health department
  services
• Explore credentialing or enrollment options
  request enrolling locations instead of individual
  providers-makes billing less complicated

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Other Contracting Resources

• The American Medical Association (AMA) has a
  number of excellent contracting resources for
  providers, including education, toolkits, and
  webinars. They also have billing and coding
  information, and many other resources useful for
  practice management.
• You can access the AMAs Practice Management page
  here
• http//www.ama-assn.org/ama/pub/physician-resource
  s/practice-management-center.page?