Has your lab or group encountered obstacles when trying to determine how to get in network with insurance companies who represent your patient population? If so, you’re not alone. Health insurance companies manage their provider networks in a variety of ways and under different strategies. Some payers simply use a network need criteria standard, while some require the lab to be located within their state or service area. These are just a few of the requirements that may restrict a lab’s participation in network.
However, even when a particular network is difficult to enter, there are strategies a lab can pursue to improve their chances of getting in network. Read on in the article below to learn more about how these approaches can help your lab distinguish itself and become an invaluable part of any payer’s network.
Target your payers, including secondary markets:
The field of outpatient labs in the U.S. is crowded, and the number continues to grow each year. The goal of these labs is to get in-network payer contracts for the patient population they serve, which is why it’s important to have a target in your mind of which payers you’re most interested in, says Brian Burns, Vice President of Managed Care Strategy for Lighthouse Lab Services Payer Strategy Solutions.
“If you’re in Ohio, for example, do you ever do business in Illinois?” says Brian Burns, who served as a managed care executive for more than 33 years with Prudential Healthcare and Blue Cross Blue Shield of Kansas City and Louisiana before moving into the consulting space. “Whatever your plans might be, identifying your primary market and secondary markets is key.”
Brian Burns also points out that utilization of out-of-network labs often increases spending for both payers and patients due to high deductibles and out-of-pocket liabilities. While these unexpected costs can be frustrating for patients, they also can potentially increase a lab’s accounts receivables and bad debt, or put them in conflict with regulations barring surprise billing.
Is the network closed? What exactly does that mean?
Have you been told a network you’d like to join is closed? If so, it’s important to understand what exactly that means as payers typically have several products, including HMOs, PPOs, and Medicare Advantage plans.
While some of these products may truly be closed, that typically isn’t the case across the board. And even when a network is tightly controlled, strategies such as diversifying your test menu can be pursued to make your lab more attractive to a particular payer.
“When a client identifies a closed network they’d like to enter, we try to drill down and determine what that ‘closed’ status truly means,” says Brennan Burns, Vice President of Payer Contracting for Lighthouse. “Then we determine if there are unique market strategies we can pursue to help position your lab in the best light to be viewed differently by a payer and get you in that network.”
Stand out from the pack:
When a network is tightly controlled or closed, one of the best approaches to showing your value to that payer is by presenting a test menu with unique and tailored offerings designed to appeal to the payer and the patients they serve.
“We help our clients highlight and develop testing that could be considered unique or proprietary and present those services to the payers as a case for why they should be admitted into their network,” explains Brennan Burns, a former contracting manager for payers such as Blue Cross Blue Shield of Texas and longtime lab consultant. “There are a number of plans we can get into if we present something that’s very unique and a value add to their network.”
Payers want to know your population:
Payers will also require lab utilization and values from outpatient labs when you’re attempting to contract with them. While lab expenses make up less than 10% of most payer’s annual claim spend, lab tests and values greatly influence clinical decision making. That’s why lab values (much like pharmacy data) are extremely important when labs are evaluating your patient population, test utilization, and other factors that could influence their decision to contract with your lab.
Quality and accreditation matter!
The overall health of your patient population also impacts quality programs and accreditations payers use to make contracting decisions. Most labs are credentialed with CLIA or Medicare, but having a COLA or CAP certificate can increase your chances of getting in network. Other organizations, such as the National Committee for Quality Assurance (NCQA) also offers several layers of accreditation based on patient health measures.
Additionally, payers with Medicare Advantage plans are evaluated by CMS through a Stars program, which drives revenue allocation and helps employers and patients determine which plans are the most quality driven and cost effective. By helping payers improve quality, keep expenses down, and maintain healthy patient populations, labs can help improve that payer’s position in the competitive healthcare marketplace and make themselves more valuable in turn.
Partner with an expert:
In such a competitive market, partnering with an expert like Lighthouse ensures your application receives the timely attention and consideration it deserves. As payers become increasingly selective due to the abundance of new labs, elevating your lab’s strengths is key.
“We stay in contact with connections we’ve built over the years at each of these plans to make sure our clients contracts stay top of mind,” says Brennan Burns, touting his team’s 40 years of combined experience in the managed care contracting space. “Being able to speak with someone directly is often much more effective than just filing paperwork or going through a website.”
If you’d like to discuss strategies for how to get in network with insurance companies or improving your existing contract, contact us today for a free consultation!