- Leverage: Identify your clinic’s leverage before entering negotiations with a health plan. How many surgeons perform ECTR in your city?
- Unique Services: Does your practice offer any unique services that will benefit the health plan and its members?
- Patient Mix: An OBS / WALANT clinic can accept patients not appropriate for full anesthesia.
- Number of Total Surgeries: Calculate how many ECTR surgeries you performed last year and the Place of Service.
- ECTR by City: Go through MCR ECTR UTIL DB numbers and map total ECTR procedures by city. Remember that these are estimates based on Medicare data. (optional)
- Calculate Total Costs: Calculate how much the surgeries cost the insurance company adding both professional fees and facility fees.
- IOECTR Projections: Calculate how many ECTR surgeries you plant to perform in your OBS suite and calculate the savings to the insurance company.
- Aim High: The higher the number the better. Remember that whatever you ask for they will likely counter with a lower figure so aim high. Facility costs are highest at the hospital, then HOPD then ASC. Work in that order.
- Balance Billing: Address “balance billing” in the contract. You will most likely have to agree to not balance bill the patient for the difference in costs. If they agree to allow balance billing I would take it. Inform the patient that they would be paying a premium for the convenience of the office-based and wide-awake surgery. (optional)
- “Facility Fee”: The focus is on negotiating a fair “facility fee” for the office-based surgery suite. See Guidebook for details.
- Efficacy, Safety: Address efficacy, safety, reduced pre-op tests, post-op care and patient satisfaction research.
- Other Issues: Determine if other procedures or other issues need to be in this contract.
If you are new to contracts or new to surgical procedures that do not have a Site of Service Differential (aka, “facility-only”) then please read our Guidebook and Posted Articles on the issue. (SOSD)