Joining the Right Team: How Providers Can Pick Winning Payer Networks

Summary

Healthcare providers should approach selecting payer networks strategically, much like professional athletes choose teams during free agency. The article outlines five critical factors for evaluation: network size and patient base, reimbursement rates, market competition, administrative efficiency, and contract terms. By carefully analyzing these elements, providers can make informed decisions that support their practice’s financial health and patient care goals.

A Free Agency Approach to Payer Networks

As autumn settles in and the sound of cheering crowds echoes across stadiums, it’s easy to draw comparisons between the teams on the football field and the strategic decisions in healthcare negotiations. Just as a pending free agent evaluates potential landing spots before signing a new contract, healthcare providers must thoughtfully assess payer networks before joining their roster.

Imagine you’re that free agent player, and each payer network is a team vying for your talents. You wouldn’t just sign with the first team that makes an offer, would you? No, you’d consider various factors to ensure you’re making the best choice for your career. Stable QB situation? How much cap space do they have?  Championship contender? Similarly, as a healthcare provider, you need to evaluate payer networks strategically to ensure they align with your practice’s goals and values.

So, what are the key factors in this decision? Let’s break down the five crucial factors you should consider as a healthcare free agent:

5 Key Factors for Evaluating Payer Networks

1. Network Size and Patient Base

The size of a payer’s network can significantly impact your patient volume. A larger network typically means more potential patients, but it’s essential to consider the following:

• Number of covered lives in your service area and the potential for new patient acquisition
• Demographics of the insured population
• Different products offered by the payer and their rates (HMO, PPO, MA, Managed Medicaid, etc.)

2. Reimbursement Rates and Fee Schedules

Understanding the payer’s reimbursement structure is crucial for your practice’s financial health:

• Compare the reimbursement rates by product to your current payers
• Analyze the fee schedule for your most commonly billed services
• Consider the potential impact on your revenue cycle

3. Market Saturation and Competition

Assess the competitive landscape within the payer’s network:

• Number of providers in your specialty already in-network
• Geographic distribution of in-network providers
• Potential for patient steerage to your practice. How much additional volume can you realistically serve?

Thinking of yourself as the prized free agent can help flip the script on payer organizations. Your goal is to make strategic alliances that will lead to victories in patient care and practice sustainability.

4. Administrative Burden and Efficiency

Evaluate the payer’s operational processes and their potential impact on your practice:

• Claims processing time and efficiency
• Prior authorization requirements
• Electronic health record (EHR) integration capabilities / demands
• Customer service quality for both providers and patients

5. Contract Terms and Flexibility

Carefully review the contract terms to ensure they align with your practice’s needs:

• Length of the contract and renewal options
• Performance metrics and quality measures
• Opportunities for value-based care initiatives
• Termination clauses and renegotiation possibilities

Remember, joining a payer network is like signing with a team – it’s a commitment that can significantly impact your future. Just as a quarterback might consult with their agent, coaches, and fellow players before making a decision, don’t hesitate to seek advice from colleagues, financial advisors, or healthcare consultants.

Thinking of yourself as the prized free agent can help flip the script on payer organizations. Your goal is to make strategic alliances that will lead to victories in patient care and practice sustainability. By carefully considering these five factors, you’re more likely to form deeper relationships with payer networks that will give you the leverage needed to get wins season-after-season.

So, analyze the field, put on your game face, and make the choices that will lead your practice to victory. After all, in the game of healthcare, everyone wins when providers and payers work together effectively.