When should an organization say "no" to a payer contract? This may be one of the most important payer contracting questions leadership can ask. The goal of contracting isn't to participate with as many payers as possible. The goal is to build a payer portfolio that supports the organization's financial and operational objectives. Sometimes the [...]
How does patient responsibility affect the economics of the contract? This, by far, is the elephant in the room form most behavioral health providers. Here's another question that can dramatically change the way a commercial payer opportunity looks: How much of the patient's financial responsibility is actually collectible? A payer may allow $175 for a [...]
What is the denial rate? Here's a payer contracting question that doesn't get enough attention: How difficult is it to actually collect the reimbursement we're negotiating? A fee schedule can look attractive on paper. But if claims routinely encounter: • Authorization issues • Medical necessity denials • Eligibility problems • Coding disputes • Documentation requests [...]
How much administrative friction does this payer create? This is one of the most overlooked questions in payer contracting. Leadership may compare two contracts based on reimbursement: Payer A: $125 Payer B: $110 At first glance, Payer A looks like the obvious choice. But what if Payer A also requires: • More frequent authorizations • [...]
What does it actually cost us to manage this Payer? A payer contract doesn't end when the agreement is signed. That's when the operational work begins. Consider everything that may be required to get a claim from service delivery to payment: • Provider credentialing • Enrollment and roster maintenance • Eligibility verification • Prior authorization • [...]
Is the higher reimbursement rate actually better? A commercial rate may be higher than Medicaid. That does not automatically make it a better contract. When evaluating a commercial insurance opportunity, reimbursement is often one of the first things organizations look at. That makes sense. But the fee schedule only tells you what the payer is willing [...]
Introduction For many behavioral health organizations, commercial managed care contracting feels like a necessary step toward growth and sustainability. But here’s the reality:Most organizations don’t lose money because of bad contracts—they lose money because they’re not operationally prepared to perform under them. Contracting is not just a legal or financial exercise. It’s an organizational commitment [...]
In our previous article, we discussed the differences between Traditional Medicare and Medicare Advantage and why behavioral health organizations cannot assume that all insurance products follow the same reimbursement rules. One of the most common questions we receive from behavioral health practices involves supervision and billing. The question usually sounds something like this: A Common [...]
As behavioral health organizations expand services and add prescribing providers, we continue to hear a common question from the field: A Common Question "Our Nurse Practitioner is individually enrolled with Medicare and actively seeing Medicare beneficiaries. Why are our Medicare claims still denying?" The answer often surprises practice owners, executives, and billing teams. Simply having [...]
From time to time, we come across questions from the field that we know affect all behavioral health practices. We’re seeing a growing number of practices run into this issue as they expand services and staffing models: Q: I have Licensed Social Workers (LSWs) in my practice who see commercial clients under my supervision, and [...]
