Initiating Contract Discussions With Health Plans

1. Initiating Contract Discussions With Health Plans Presented by Lisa Park Healthcare Reimbursement Manager Virginia Department of Health lisa.park@vdh.virginia.gov January 15, 2013

2. 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.

3. 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 doesn’t? One-stop shop, walk ins.

4. 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.

5. NCQA’s 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 plan’s overall score.

6. NCQA’s Health Insurance Plan Rankings, Cont’d. • 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.

7. 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 plan’s ranking.

8. In Summary--Where do you fit in? • Health department provider contract=claim submission for services that are likely part of NCQA’s 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)

9. For More Information… • The 2012 NCQA’s 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

10. 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.

11. 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 termination—this 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

12. 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

13. 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 AMA’s Practice Management page here: • http://www.ama-assn.org/ama/pub/physician-resources/practice-management-center.page?