|
Re-contracting PPO and Vaccine Reimbursements
I speak to many physicians and office managers who give me a similar story. They say that their PPO reimbursements are low and that they do not receive adequate payment for vaccines. In some cases the reimbursement for an individual vaccine is less than they pay for it. This occurs because the contracts with the PPO or health plan have not been renewed in many years. Many of the plans will not increase reimbursements until you ask for it.
Here is what you do in the PPO situation.
- Make a list of what each PPO pays for a 99213 intermediate visit.
- Take the lowest paying plan and call contracting.
- Ask to speak to a supervisor about increasing your reimbursement.
- Be polite and direct about how low they are paying and ask for an increase.
- They usually try to make it hard and ask you to write a letter. Get their fax number and a name to send it to. Write one and get it off immediately.
- They usually say they will get back to you in 7 days. Not one has come back to me yet. In 7 days call them again and inquire. You have to be aggressive and persistent.
I have been successful in almost all cases. One case comes to mind. When they denied me a raise, I reminded them that I had 122 of their patients and that I was a pediatrician. Each patient had 2 parents and in many cases the parents had different insurances. They could still come to me if they switched the insurance to the other parent. My patients would not like to change their insurance plan just to stay with me: But most would. A few days later, I received a call and they gave me 1.25 times the RBBS for my area. Since they were previously at a multiple of .85 of the medicare rate, I felt that I had won my case. I ended the conversation with the statement, “Thank you very much. I will accept the rate, but when your rate drops too low again, I will call you back.”
Contracting for a vaccine reimbursement is a little different. The PPO or IPA must use the Average Wholesale Price (AWP) upon which to base their reimbursement. They try to ask you, “What do you pay for the vaccine. Send us an invoice.” This isn’t legal. What you pay for a vaccine is your business. They have no right to the information. That is why Children’s Healthcare gets you discounts off the stated price. They must also give you a reimbursement that is more than you pay for each vaccine. The law mandates it.
A major reason that a reimbursement is lower than the price of the vaccine is that the contract is old and has not been renegotiated. Call the plan up and speak to the contracting department. Get a supervisor and get a new updated contract. They will try all of the tricks:
- “I’m sorry the supervisor isn’t in.” = “Please let me speak to their supervisor.”
- “Please put it in writing.” = “Where and to whom do is fax it? When will I hear back?”
- “We will make a decision in 7 days.” = “I will call you back.” Mark your calendar.
- Get the supervisor’s direct telephone number and a case number if necessary so you don’t have to go through the phone tree again.
- If it really gets nasty, keep your cool and continue to be polite. They don’t like to hear things like:
- “I heard one group filed a grievance.”
- “Isn’t there a law that says I have to be paid according to the price?”
Ultimately, you will be successful.
Currently there is no media on this page
|
