notepad with 6 checked boxes

6 tips for evaluating insurance plans

The Affordable Care Act (ACA) will change the insurance market. Whether through new health insurance marketplaces or other sources, optometrists will have new opportunities to participate in plans.

When you evaluate these plans, don't be haphazard, cautioned Charles B. Brownlow, O.D., an AOAExcelTM consultant who writes and lectures on third-party payer issues. Carefully evaluate all provider agreements—just as you would any major investment or purchase. And be prepared to negotiate.

"Many practitioners simply never bother to ask."

"In many cases, insurance plans will consider changes in their provider contracts to accommodate the needs of individual practices," Dr. Brownlow said. "However, many practitioners simply never bother to ask."

Dr. Brownlow suggested the following six steps during his presentation at the AOA State Legislative and Third Party National Conference:

1. Meet with your team

Your practice accountant and other advisers can help you develop parameters for acceptable provider agreements. The parameters should be based on your practice's established fee schedule, scope of practice, needs of patients and other considerations. To legally comply, you must not collaborate with other practices to establish parameters. They need to be unique to your practice.

2. Perform research

Research all current contracts under which your practice provides care. If you can't find a contract, contact the insurer and ask for a copy of the plan's current provider contract, as well as the next renewal contract, if available. Add any prospective provider agreements to your research, too. 

3. Compare parameters and components

Revisit the parameters you developed in step No. 1, and compare them to the components of each provider agreement you researched in step No. 2.

4. Consider joining

If the components of the contract meet or exceed the parameters established for your practice, consider joining the new plan or renewing the contract.

5. Be ready to negotiate

If one or more of the components falls short of your parameters, prepare to negotiate with the insurer. Inform the insurer you would like to negotiate some components before accepting or rejecting the contract or renewal.

6. Work with the insurer

If the insurer is willing to negotiate, work constructively to reach the best agreement possible. If the insurer refuses to negotiate, discuss the options with the practice accountant and advisers and make a decision.

"Even when insurers have a 'take it or leave it' approach to their provider agreements, practitioners will almost always be better off knowing that their decisions on third-party coverage have been made based on sound principles and procedures," Dr. Brownlow said.

October 16, 2013

comments powered by Disqus