'Avoid contracts that do not meet your costs': How spine surgeons should approach payer negotiations

Payer Issues

Negotiating with payers is one of the most important, if most challenging, aspects of a physician's practice. For surgeons seeking to boost reimbursement rates or ensure bills and claims are paid out as expected, there are a few factors to keep top of mind.

Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. Becker's invites all spine surgeon and specialist responses.

Next week's question: How do you anticipate management services organizations (MSOs) playing out in the orthopedic landscape in the next five years?

Please send responses to Alan Condon at acondon@beckershealthcare.com by 5 p.m. CDT Wednesday, Sept. 121.

Editor's note: Responses were lightly edited for clarity and length.

Question: How can spine practices ensure they get the best contracts possible when negotiating with payers?

Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: If one has to contract with payers, come armed with outcome data such as ODI, NDI and postop med usage. Certain payers will be reasonable and want to retain good surgeons in their network. Make sure you have carve-outs for certain procedures such as disc replacement or endoscopic surgery that provide good value. Remuneration should be commensurate with the quality of work you do, and restoring your patient to health and functionality. 

Praveen Mummaneni, MD. University of California San Francisco: When negotiating a contract, surgeons must understand their overhead costs. Avoid contracts that do not meet your costs. The cost of doing business in the San Francisco Bay area where I practice is high. Overhead costs for labor and space are driving costs. The contract must compensate for the cost to be worthwhile. 

Furthermore, the surgeon must understand their local market. In your local market, is it important to be a surgeon who sees a large volume of patients or a surgeon who sees fewer patients but spends more time with them? If you choose contracts based on volume but low reimbursement, be prepared to spend less time with patients who then may not choose you as their surgeon. 

Grant Shifflett, MD. DISC Sports & Spine Center (Newport Beach, Calif.): It has become increasingly difficult for spine surgeons to obtain adequate and appropriate reimbursement for helping patients get their lives back. Insurers are often looking to provide the cheapest care possible — irrespective of quality provided. Depending on the competition in your particular geographic area, it simply becomes a game of racing to the bottom to accept the lowest payment just to get a contract.

Yet, the days of fighting against insurance companies are over. If we want to see higher reimbursements, we need to find a way to work with them and we must do it as a united front. An independent physician may not get enough recognition to impact real change, but physician groups coming together can make a difference. At DISC, we're leveraging the scope of our entire practice to have meaningful, data-backed conversations with key payer leadership.

Through this dialogue, insurers are recognizing that there is an opportunity in optimizing site of service and prioritizing quality to create a savings that benefits payers, patients and providers alike. They are seeing that the shift of high-quality, minimally invasive, motion-preserving cases to more specialized environments like state-of-the-art ASCs enables better care at lower costs, which, in turn, allows physicians to get higher reimbursements.

Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): Healthcare contract management is all about resolving digital efficiencies and adopting practices to streamline the processes, minimize the risks/costs and meet regulatory compliance. Current recessionary economics and crippling personnel issues will curtail healthcare delivery, as wait times for specialty medicine protracts. This seems to have worsened as patients are more keenly aware of cost, travel and wait expenditures add up. Surety providers will be called upon to facilitate and assist in delivery measures. 

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