Tips for Building a Trusted Payer Relationship

Because 54% of the Medicare population is covered by Medicare Advantage (MA) plans (according to Kaiser Family Foundation) and 75% of Medicaid recipients are enrolled in managed care organizations (MCOs) (according to Medicaid.gov), forging and maintaining interest in third party payers is essential. Learning how to have a positive relationship with the payer should help obtain and maintain contracts. Once a contract is secured, minimizing denials and avoiding compliance issues is an ongoing challenge. Let’s look at how to manage those tasks.

Communication

The key to working with the payer community is finding ways to collaborate through practical communication efforts. From the outset, your goal should be to learn the payer’s pain points and concerns. Research the company and learn key facts about it,­ such as the company’s number of covered lives, geographic and socioeconomic demographics and core values.

In addition to the payers’ websites, you can find information by scouring LinkedIn and sources like the Kaiser Family Foundation. In addition, attend payer trade shows (e.g., AHIP) to learn about systemic issues trending from the insurance company perspective. Most importantly, use the time to network and get to know key stakeholders at the payer level. As always, if you find one contact, make another. Having at least two contacts means that when one leaves, you can rely on the other until you meet their replacement. Sit on boards and/or volunteer in places where you might meet and get to know more of the payer community. These efforts will take time and dedication, but the rewards should make it worthwhile.

Trusted Relationship

Forging a trusted relationship enables you to work in collaboration with payers. When attending home medical equipment (HME) conferences where payers are present, engage them in conversation—then you can educate them on relevant topics.

Persistence and reliability are key. For example, one payer at a recent conference presentation said they were having trouble getting HME providers to cover their member needs in remote areas. By filling this gap for the payer, one supplier was able to negotiate a contract they had been trying to obtain for several years. Taking this negative and turning it into a positive meant the payer could rely on the HME supplier, and they became a favorite to Medicare Advantage members. Understanding payers’ pain points and solving them can help you leverage the relationship.

Collective Voice

As you navigate third-party payer relationships, you will find that seeking an answer or making changes is sometimes met with resistance. Your state and national associations, such as the American Association for Homecare or groups like VGM can often find the person with the answer you need.
You should share your questions and concerns and attempt to remedy them as a collective voice. Becoming involved on committees in these organizations can make it possible to reach decision-makers at the payer level.

Contracts

Obtaining a contract may take a valiant effort and enable an HME provider to grow and expand their services. But some contracts—those that are mostly unprofitable—are not something in which most providers want to engage. The first thing to do if you are invited to contract with the payer is to ensure that you will not be left with an unprofitable outcome. Saying no is sometimes an inevitability if the payer is not willing to negotiate and their pricing or terms make it a money-losing proposition.

After scouring the contract for key terms and elements (such as in and out of network, ancillary services, payment terms, prior authorization requirements, medical necessity and appeals process, to name a few), ensure the payer requirements are readily known and easy to access. Ask how and when they will inform you of changes and how far in advance you will know of an update. Ask how often they will meet with you to review the progress of the relationship. This should be done regularly—some HME suppliers meet monthly with their payer contractors. Ask who your point of contact is for specific matters such as qualifying patients, reauthorizations, etc. And ask if they follow Medicare guidelines and, if not, how they establish their requirements and if you can read them in advance. Remember: They can no longer make their requirements more stringent than traditional Medicare.

General Contract Terms

In addition to specific requirements, a contractor’s motivation and profitability factor must be known. Speak their language and be prepared to renegotiate as needed, especially when they lack defined requirements and terms.

In all of this, you should establish a partnership with the payer and influence them for their best interest—and yours, too. For example, if you see rules assigned to prior authorization but not to reauthorization, ask for them. If they don’t establish rules around patients who switch from other payers to their MA plan, ask, since federal guidelines now require a minimum 90-day transition period, during which the new MA plan may not require prior authorization for active service. Addressing these matters before signing the contract is the best case scenario.

Rules Engine Automation

With dozens of plans offered in some areas just for Medicare recipients, you are bound to have to remember countless rules and regulations—while processing orders. You are forced to keep track of payer requirements by way of a matrix, template, some type of database or an Excel spreadsheet.

The best way to handle the information is to build a rules engine into your software (or add it to the software via an API) that proactively remembers what is needed for a proper order. This will help avoid denials and invalid orders and enhance your chances of compliance and first-time payment. For example, if the rules engine knows a certain prefix means the patient is out of network, it will tell the user that this order will be paid to the patient and not to the supplier. Before engaging in a long intake process, the intake representative can decide how to best proceed.

More of this kind of software will become commonplace in the coming years. It will enhance the number of viable orders and reduce the amount of time spent correcting denied claims. Further, it will help reserve staff time for more analytical matters. Whether you have a rules engine, matrix, template or something else, dedicate a resource to staying on top of the payers’ changes and have them monitored for appropriateness. The bottom line is that you need staff to monitor the contract for adherence and changes by auditing claims and reviewing contract terms and nuances.

Compliance & Audits

Stay on top of issues before they erupt with open dialogue and communication; having a payer relations person or team helps because they’re a liaison who talks regularly with the payer. Create safeguards that ensure the operations teams inside your organization stay abreast of payer changes, new licensing requirements, pricing modifications and other internal operational processes that staff needs to know. Use training tools and in-services to be certain everyone involved with the payer knows of the requirements and changes. Consistency and constancy will provide you with the necessary tools to stay in sync with the payer and the partnership.

Consistency & Open Dialogue

Staying on top of changes will help the payer know that you are motivated to do the right thing. It also keeps the channels of communication open. Scheduling a monthly meeting is a common way to stay up on current trends and to discuss your progress. Knowing the payer’s objectives and remaining steadfast in your effort to adhere to their requirements means you are forging a lasting relationship based on trust and respect.