| Typically many hospitals and IPAs struggle to | | | | 3. If payment is based on coding, which version is |
| complete managed care negotiations in a timely | | | | used? How quickly will updates be incorporated? |
| manner and with the optimum terms possible. | | | | 4. Is the plan allowed to withhold payments? How |
| Most management teams are already stretched | | | | much? Under what circumstances must the plan |
| thin and lack the necessary time for proper | | | | pay back withholds? What rights do you have if |
| research and back-and-forth wrangling. As a | | | | you disagree with the plan's decision to keep a |
| result, negotiations are often completed late and | | | | withhold? |
| below market rates. | | | | 5. Does the plan have to account for the |
| Like any negotiation, knowing how far the other | | | | disposition of monies it withholds? If so, how (e.g., |
| side will go is the key to successfully negotiating | | | | quarterly financial reports)? |
| rates and terms. However, because directly | | | | 6. What types of incentives or bonuses can you |
| comparing rates with other hospitals and IPAs is | | | | earn? Quality? Outcome? Efficiency? Cost? |
| difficult, another means of obtaining market | | | | 7. Do you know exactly what you're supposed to |
| intelligence is needed. A solution many successful | | | | do to earn incentives or bonuses? |
| hospitals and IP As use is to hire a third-party | | | | 8. Are there any incentives for members to |
| negotiator well-versed in the rates and | | | | obtain their care from you? Are these incentives |
| approaches of the various health plans. | | | | to use your services at least as favorable as |
| Critical pieces of the Healthplan Agreement are | | | | incentives to use other network providers? Do |
| the Compensation Areas. 12 Questions The | | | | referring providers have incentives (or |
| Athena Group uses are taken from their booklet. | | | | requirements) to refer in-network? |
| Do you know the answers to these questions for | | | | 9. If a member changes providers during a course |
| all of your Healthplan Agreements? | | | | of treatment, how is compensation allocated? |
| The Athena Group uses extensive contacts, | | | | 10. Under what circumstances are you entitled to |
| market intelligence and these 129 questions to | | | | rate increases? |
| help hospitals and IPA's speedily negotiate more | | | | 11. How are rate increases determined? By annual |
| favorable managed healthcare Agreements. | | | | revision based upon a formula such as inflation? |
| 1. How much compensation is to be paid and how | | | | By pegging rates to independent factors, rates, or |
| is it to be determined? | | | | measurements like the Medicare reimbursement |
| 2. Are you comfortable with the payment | | | | rate? By annual renegotiations? |
| methodology they are offering? Is it radically | | | | 12. Does the plan have the right to "most favored |
| different from the payment methodology used | | | | nations" rates? |
| by your other contracted plans? | | | | |