Don't Hesitate to Negotiate Managed Care Contracts

As a follow-up to an article published in this column on September 18, 2009, on what to look out for in contracts with insurers or managed care organizations, here is some advice on negotiating contracts.

Many managed care organizations (MCOs) are encountering difficulties in keeping enough psychiatrists in their networks to provide adequate coverage for their members. Because of this, you may have more leeway in negotiating contract terms and fees than previously. Don't be afraid to ask for what you want. You may not get it, but you lose nothing by asking, and you may get more than you anticipated. If the insurers won't budge, then you can decide whether to accept their terms. You lose no points for making clear what you want or for accepting the terms originally offered if your suggested terms aren't met.

APA's Managed Care HelpLine recently received a call from a psychiatrist in the Northeast. He was being pressured by a large MCO to join its network. It had recently purchased a smaller network that included 50 of his patients, and he had received several calls asking him to join the larger network. He was warned that when the integration of the two networks was completed (a date that kept being postponed), his patients would be notified that he was no longer in-network if he failed to join in time. The company sent him a copy of the fee schedule it was offering, and the reimbursement was lower than what he was getting from the smaller network (where, by the way, fees had not been increased in many years). He declined to join the larger network, but he called the Managed Care HelpLine because he was worried about exactly what to do. He believed that he'd probably have no choice but to join the new network eventually, but in the meantime, he didn't want his patients to receive the promised notification that he was an out-of-network provider.

HelpLine staff suggested that he contact the MCO “expansion network manager” who had asked him to join the network and request a response in writing about when the integration of the two networks would take place and whether he would have time to become part of the network before his patients received notification that he no longer participated. After the manager told him the integration would not occur for another four months and that he'd receive 60 days' notice of the switch while his patients would receive 30 days' notice (giving him 30 days to decide what he wanted to do), she apologized about having supplied him with an inappropriate fee schedule. It had been a mistake, she said—the fees specified were far too low for his location. She e-mailed him the correct fee schedule, and much to his amazement, the fees were higher than what he was currently receiving. Had he joined the network at the previously offered reimbursement level, one can be reasonably sure that's all he would have been paid.

Subsequently the doctor called the HelpLine with another question: Would it be a mistake for him to ask for even higher fees, closer to his private-pay fee schedule? The answer: absolutely not. The HelpLine hasn't heard whether he got the even higher reimbursement rate, but he lost nothing by asking.