1. Retrospective review. Watch for clauses limiting the amount of time the payor can review paid claims for mistakes (and overpayments). A time limit for retrospective review could prevent you from having to pay for indefinite claims errors on the part of the payor.
2. Termination for cause. You want to make sure, if you possibly can, to have 30 or 60 days notice to terminate a contract without cause, says Ms. Charkin. You don’t want it tied to the anniversary date of the contract. “The way the contract is written is they’ll let you terminate within 180 days of the anniversary date,” she says. “Then you have to figure out what the anniversary month and then kick back 180 days; a lot of times you’ve missed that window of opportunity and then you’re stuck with your contract for another year. The payers do that because they don’t want you to terminate.” If this clause is included but the payer isn’t paying you according to contract, you can still terminate for cause.
3. Payor proprietary fee schedule. Make sure the payor is required to adhere to the contracted rates. “A lot of times what you’ll see is they’ll pay you the “payor proprietary fee schedule,” which means absolutely nothing because they can jerry-rig that rate any way they want,” says Ms. Charkin. “You want to make sure that after you finish with your negotiations, your payer physically gives you the rates for the contracted codes so when the claims come in, you can appropriately adjudicate and make sure they are paying you according to contract.”
You also want to make sure they can’t change the rates, she says. Oftentimes a payor will reserve the right to modify the fee schedule.” Why contract if they have the ability to change the rates?” she says. “Sometimes they won’t be willing take that out, but you can say that if you modify your fee schedule, you have to give us 60-days notice by certified mail and if you do that, then we have the ability to terminate without cause. You want to make sure that kind of language is in there as well.”
4. Silent PPO provision. If payors include this clause in your contract, it gives them the right to sell the contract to other payors who can then access your contract and the rates you agree to. “The way these payors make money is not only selling to the employer groups but they sell these contracts to all of these self-insured companies,” says Ms. Charkin. By doing so you may be agreeing to give discounts to low volume patients or employer groups that would otherwise come to your center through another agreement at higher rates.
“If you can, negotiate those out,” she says. “That’s usually pretty hard to do, so if you can’t, you can still use that as leverage to do other things.”
Learn more about Healthcents.
