Part One–The Curious Case of Missing Fee Schedules
By: Tarah Vanhooser, VP of Ancillary Services
This three-part blog series delves into independent providers’ challenges when navigating payer contracts, fee schedules, and prior authorizations. It also explores the lack of transparency and accountability and how these issues impact healthcare providers’ business operations.
One of the first lessons we learn is the importance of keeping promises–our trustworthiness depends on it.
Since the Roman Empire, successful business partnerships have relied on mutually beneficial contracts. When executed properly, business partners act in good faith, clearly stipulating the expectations, or “terms and conditions,” for the relationship.
This is especially true in the business world where promises, or contracts, act as the foundation for our market economy.
The Physician-Payer Promise
Promises are essential in the healthcare industry.
Clinicians pledge to do no harm to their patients, and patients agree to compensate physicians for providing medical care. Physicians assure payers that they will provide medical treatment to members of the payers’ insurance plan networks, and in return, payers promise to reimburse these physicians based on published fee schedules.
However, some payers are failing to hold up their end of the bargain when enrolling independent healthcare providers. This results in smaller physician groups entering contracts without full knowledge of the terms, leaving them in a vulnerable position.
Physicians cannot enroll in government or commercial insurance plans without proper credentialing.
As the VP of Ancillary Services for Advantum Health, my team supports our client healthcare providers with two essential requirements for entering contracts with payers: credentialing and completing physician enrollment applications.
Working diligently behind the scenes, my team, Provider Enrollment Services (PES) ensures that healthcare providers have the proper education, training, and licenses to deliver services within our healthcare system clients’ networks.
Before a medical practitioner can legally provide counsel, consultations, or treatments, they must meet state and federal requirements for their scope of practice. Overlooking this crucial step, known as credentialing, can have devastating effects on patient safety, the practitioner’s career, and the financial stability of the healthcare system.
Without proper credentialing, a physician cannot enroll in government or commercial insurance plans, hindering their ability to receive reimbursements for their services.
Complicating matters further, some payers have created additional challenges for independent healthcare provider groups.
Payer contracts increasingly lack fee schedules.
For our healthcare provider clients, the fee schedule is a crucial consideration when deciding whether to join an insurance plan’s network.
Before entering into a contract with a specific insurance plan, providers, especially independent physician groups specializing in expensive services like cardiovascular surgery or gastroenterology, need to assess the financial implications of their choice.
But, lately, several payer contracts do not include fee schedules.
When we reach out to the payer for a fee schedule, we are often directed to a provider portal. However, we cannot access the portal due to our client’s lack of login credentials since they are not yet enrolled. Even if we can access the portal, often we cannot retrieve the fee schedule until we enroll in the plan.
This situation leaves many physicians in a difficult position.
With many of their patients enrolled in these plans, every day represents a potential revenue loss. As a result, our physicians are forced to sign the contract without knowing whether it makes financial sense for their practice, hoping they have made the right decision.
The provider enrollment process typically takes 60-90 days to complete. Still, we’ve experienced some that can take up to 6 months, which can take a significant financial toll on a small physician practice. Physicians feel pressure to get enrolled as quickly as possible to generate revenue, especially for independent physician groups (IPGs) with limited resources to perform the tasks.
In the past, enrolling in an insurance plan’s network included 5-6 steps:
1) Complete the provider application
2) Receive notification of acceptance or a denial
3) Review the insurance plan contract and fee schedule
4) Assess financial impacts of reimbursements
5) Negotiate fee schedule if necessary
6) Sign the contract to join the plan’s network or remain an out-of-network provider
This is the rare situation in our industry when I would like to return to the “good ole days.”
Even with these challenges, the Advantum Health PES team works tirelessly to verify provider credentials and help our clients quickly enroll their physicians in insurance plans.
Conclusion
To be fair, most insurance plan contracts include missing fee schedules, but that’s not the point.
The silent removal of access to critical information by payers significantly hinders healthcare providers’ ability to make informed business decisions. Left feeling helpless, providers and third-party delegates, like myself and my PES team, resort to social media crowdsourcing for guidance on locating fee schedules or seeking referrals from acquaintances with access.
It is puzzling why the payer transparency for provider fee schedules is not held to the same standard as price transparency for patients.
Again, it’s frustrating to watch clients “hope for the best” when choosing to go in-network with an insurance plan when the IPGs are the most vulnerable to the implications of a bad decision.
Not only does our industry need a No Surprises Act for patient billing, but we also need a No Surprises Act for fee schedules to protect independent healthcare providers.
Find out more here to read the next installment focused on prior authorizations and learn more about Advantum Health and how we can partner with you for provider enrollment and credentialing.