Trench Stories I (or, “Harnessing Mom Power”)

Over the next few days, I'm going to post a sampling of stories of the things I've seen from our clients just this week regarding insurance negotiations. As so perfectly put by Dr. Rogu in a recent comment, awake sleeping giants! Identifying information has been removed.

So, from client #1:

...after review and some quick negotiation, it was obvious they were not willing to budge. We were done. A few companies had moved to [HMO] but not a major problem. Recently (the July 1 thing) the [local] union decided to go with [HMO]. Moms asked what they needed to do to get us to sign with [HMO]. I replied to two that we had reviewed the contract and there were major problems. Unfortunately, [HMO] was unwilling to make any changes. Naturally, I added, "They may listen to you. We would be willing to talk more if [HMO] is willing." I could almost hear you whispering in my ear, "That is just what you should say."

These moms, along with several of their friends who also bring their children to us, went to the enrollment meetings and talked to the union officers. I will avoid the specifics, but it wasn't pretty. Within one week, [HMO] reps were back talking to us and with a significantly higher reimbursement rate. Of course, we wanted to see the entire schedule and noted vaccines were paid at a low rate (their "purchase price" was below AWP). They did offer to allow us to enter their buyer's group. Secondly, we negotiated an increase in codes that had no "Medicare value" from the 60% you mentioned in your post to 80-85% depending on the plan. This improved the non listed administration fee from 60% of billed charges to 80-85% of billed charges.

After discussion, we have decided to "adjust" the administration fee for imms administered to [HMO] patients to reflect our administration costs INCLUDING the cost of ordering, storing, and cost of money. We are happy with this and think it is cool that Partner already has this capability.

Always one to keep pushing our clients, I asked: "How much is the difference worth?"

The answer?

It is my understanding that payment went up 20-25% in the 140% of Medicare for E&M codes. Total counting lab, x-ray, and imms put us at 125-130% of Medicare.

Anyone else here routinely getting 125-140% of Medicare?

There are many great things about this post, but there's one huge lesson to learn:

Don't tick off the moms.