Contract negotiation is an often-requested part of the insurance credentialing process. Below are a few important points:
For smaller private and solo-practices, many times contracts are not negotiable, depending on the insurance company. For example, Blue Cross Blue Shield will often not negotiate. However, other companies, such as Aetna, will often negotiate even with smaller practices.
In contrast, for larger practices and facilities, there’s always a negotiation about what the insurance company will cover. Practices need to be careful with the credentialing contracts.
First, if the contract doesn’t identify that a service is covered, the insurance company is likely not to pay for that service.
Also, some insurance contracts group services together. When this is the case, exact reimbursement can be difficult to determine and organizations need to be careful that the contract is going to be financially acceptable.
Thirdly, sometimes a facility will need to alter their services slightly to make them reimbursable and written into their contract. For instance, in one situation an insurance company didn’t want to cover a facility’s nutritional education. Knowing this, the facility modified the way they provided the service to make it acceptable to the insurance company, and the service was written into the contract.
Reimbursement rates are always an issue, of course. When it comes to reimbursements, even small practices need to be careful as far as “evergreen clauses” go. Evergreen clauses mean that the practice gets the same reimbursement, even if the insurance company raises their rates at a later time and is paying more to other practices.
Knowing the most current rates—which insurance companies aren’t always eager to give out—is important to re-negotiating a fair fee schedule.