7 payer contract terms to monitor as health exchanges launch

Why This Topic Matters

It helps practices recognize contract language and payer-policy changes that can affect reimbursement, cash flow, and network participation during a major coverage and coding transition.

Article Sections

1. Introduction

   Overview of the risks practices may face when health exchange coverage and payer contract renewals overlap. Sets the context for the revenue cycle and contract management discussion.

2. Passive payer amendments

   Discusses amendment language that may take effect without affirmative action. Focuses on the importance of reviewing contract changes tied to exchange participation.

3. Obscure payment information

   Covers concerns about unclear payment-rate information in amendment language and the need to understand how exchange-related fee schedules are presented.

4. Open panel commitments

   Addresses network participation terms that can be linked to higher rates. Highlights the broader contracting and patient-panel implications of those commitments.

5. ICD-10 payment tightening

   Reviews payer behavior expected during the transition to ICD-10 and the general types of diagnosis-code restrictions practices may encounter.

6. Push for cash flow protection

   Discusses ways providers may seek temporary payment protection during coding-related processing delays. Emphasizes maintaining continuity of cash flow through the transition period.

7. Network around contracting experiences

   Encourages practices to gather information from peers, media, and professional groups about payer implementation issues. Frames the value of shared contracting experience during transition planning.

8. Don’t assume you’ll know patients are in exchange plans

   Explains that exchange plans may not be obviously labeled and may require additional front-end verification. Focuses on identification and administrative awareness rather than plan details.