PREFERRED attended the annual Network Contract Optimization meeting in March 2005 in Las Vegas, NV.  The following is information regarding research that was conducted, keeping in mind that some of the points of aggrevation were mutually expressed by payors and providers, along with examples on what aggravates providers:

1. Unfair Business Practices

• One-sided contract terms
• Non-disclosure of “proprietary” claims adjudication/editing software and rules (e.g. “Claim Check”)

2.  Create Administrative Complexity

• Account specific service carve out vendors
• Confusing member ID cards

3.  Require Providers to Accomplish Great Feats to Get Paid

• Multiple requests for the same clinical records due to documents commonly lost
• Cumbersome and time-consuming authorization processes

4.  Poor Communication

• Poor response time to phone and e-mail inquiries
• Claims denied with inadequate explanations

5.  Non-Payment for Necessary Services

• Administrative denials resulting in zero payment
• Penalty for non-compliance with secondary payor rules

6.  Transfer Traditional Plan Responsibilities/Risk to Providers

• Insurance risk transfer (e.g. providers on the hook for retro enrollments/disenrollments)
• Risk of non-payment or reduced payment due to plans shifting cost to members

7.  Deploy Unprepared or Unqualified Contracting and Provider Relations Staff

• Payment recover activity contracted out to companies that fail to familiarize themselves with     contract terms
• Provider relations staff unfamiliar with contract terms and corporate policies

8.  Demonstrate a Lack of Concern about Unique and Provider Specific Issues

• Failure to acknowledge the impact of material differences between providers, such as service mix and geographic/demographic factors
• Failure to consider significant government shortfalls as “reimbursable costs”

9.  Solutions to Problems are Applied Network-Wide, even when the Problem is Not Network-Wide

• Radiology management programs
• Establish Provider Obligations that Require a Significant Investment of time and Money… With No

      Significant Benefit to the Provider

• Multiple requests for the same medical records
• Consumer driven plans that require additional collection efforts and which will result in more bad debt

Lastly, the presenter explained what providers really want from a health plan… besides good rates:

• Clearly defined and consistently implemented guidelines and policies
• Timely communication
• Responsiveness to issues
• Respect the clinical acumen of providers
• Understanding of the providers’ financial needs
• Predictability and consistency
• Honesty and integrity
• Eliminate barriers to getting paid
• Payment arrangement that can be administered by the claims processing system
• Real time eligibility data