decisionhealth Newsletters, Part B News - 2016 Issue 4 (April)
Plan underperforming? Fire them – but follow the rules
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Article Overview
This article explains how medical practices can assess whether an insurance plan is worth keeping, negotiate for better terms, and exit contracts when needed. It focuses on practice management considerations such as utilization analysis, payer leverage, contract renewal timing, patient notice, continuity of care, and back-office preparation. The piece is aimed at physicians, administrators, billing staff, and practice managers who handle payer relationships and contract decisions.
Why This Topic Matters
Underperforming payer contracts can affect revenue, staffing burden, and patient flow, while contract termination can trigger notice requirements, continuity obligations, and administrative risks. Understanding the broad process helps practices avoid missed deadlines and transition patients and staff more smoothly.
Article Sections
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Should I stay or should I go?
Explains the factors practices may consider when evaluating payer performance and overall contract value. The section discusses utilization, patient volume, administrative burden, and broader strategic considerations.
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Exit strategy
Covers contract renewal and amendment timing, notice mechanisms, and steps practices may take when planning to terminate participation. It also addresses communication practices that can affect the exit process.
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How to notify patients of changes
Describes the patient communication issues that may arise when leaving a plan and the types of notifications practices may need to provide. It also notes confidentiality and transition concerns.
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Continuity counts
Discusses continuity-of-care obligations that can extend after a plan termination and the operational steps practices may need to prepare for. The section also mentions scheduling and billing workflow considerations.
What You Will Learn
- How practices can evaluate whether an insurance plan is worth retaining
- What broad factors affect payer contract decisions beyond reimbursement
- How contract renewal and amendment timing can affect an exit plan
- What patient notification and transition issues can arise after leaving a plan
- How continuity-of-care obligations can affect scheduling and billing workflows
Who Should Read This
- Physicians
- Practice managers
- Office administrators
- Billing staff
- Revenue cycle teams
- Healthcare consultants
Codes Discussed
Code Ranges Discussed
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