Contracting With Payers: Understanding Different Plans

In healthcare contracting, providers often grapple with various payer plans and navigate the intricacies of participating in-network with different insurance offerings. The assumption that credentialing and contracting with payers automatically includes all their plans is a common misconception. In this blog post, we will shed light on the importance of understanding the different plans offered by payers and how to ensure you are contracted appropriately to avoid potential pitfalls.

The Pitfall of Assumptions

When working with payers, avoiding making assumptions about the plans you will be participating in as an in-network provider is crucial. Being contracted with a payer does not necessarily mean you have access to all the plans they offer. Each payer may have multiple plans, including commercial, Medicaid, and Medicare, as well as HMO and PPO options. For instance, you might be contracted with a commercial plan but not have access to their HMO plans. This oversight can lead to unexpected claim denials, delayed reimbursements, and frustrated patients.

Verifying Participating Plans

To ensure a smooth and profitable contract with payers, you must verify the specific plans you will be participating in. When contracting with a payer, ask the representative which plans are available to you as an in-network provider. This inquiry should encompass commercial, Medicaid, Medicare, HMO, and PPO plans.

Prior Authorization Requirements

Different plans may have varying requirements, such as prior authorizations. For instance, HMO plans often require prior authorization before patients receive services from out-of-network providers. Failing to obtain prior authorization can lead to denied claims and financial losses for your practice. Ensure your front office staff is well-informed about the specific requirements for each plan you are contracted with to avoid these issues.

Creating a List of Participating Plans

To maintain clarity and consistency in your practice, consider creating a list of participating plans for your staff. Clearly outline which plans you are contracted with under each payer, including any specific requirements like prior authorizations. This list can be a handy reference tool for your front office staff to ensure they correctly identify and handle patients’ insurance plans during scheduling.

Utilize Available Resources

Payers often provide resources and guides to help providers navigate their plans effectively. Use payer portals and websites to access information about participating plans, prior authorization requirements, and other relevant details. Additionally, maintain open communication with payer representatives to seek clarification and guidance whenever necessary.

Embrace Diligence and Curiosity

In the ever-changing healthcare landscape, staying informed is crucial. Read contracts carefully, take notes, and seek guidance from your payer relations representative. Remember, there are no foolish questions when it comes to the success of your practice. Always prioritize clarity and understanding to ensure you are contracted with the appropriate plans.

Navigating contracting and credentialing with payers requires a keen eye for detail and diligence. Avoid assumptions about participating plans and take the time to verify the exact arrangements offered by each payer. Create a clear list of participating plans for reference and ensure your front office staff is well-versed in the requirements of each plan. Utilize available resources and communicate effectively with payer representatives to streamline the process. By embracing curiosity and staying informed, you can make your practice successful and ensure a seamless experience for your team and your patients.