Statmed Open graph 2 | 4 Steps to Follow for a Rate Increase | STATMedCare Payor and Physician Enrollment and Credentialing

In today’s world, you hear about colleagues who have sold their practices to a hospital system or an ACO (Accountable Care Organization) and you wonder if you’ll be next. Why? Because shrinking reimbursement rates and stricter guidelines have made it difficult to practice medicine in a solo or small group setting.

However, there are things you can do as a solo or small group to increase your reimbursement rate with payors. An increase in your contracted insurance reimbursement rates can lead to a significant increase in revenue that positively impacts your bottom line.

Below are steps to follow that could help you obtain an increase in your reimbursement rates:

1. Gather your clinical data

Pull together a list of clinical data that includes the number of individuals you treat for the insurance company you are appealing to for higher reimbursement rates. Of those individuals, pull any data that may show that you are a responsible provider. Items such as your generic prescription rate, hospitalization rate, A1C control, blood pressure control, etc. When gathering clinical data, think of things you do that save the payor money. You want to show them that you are a responsible provider who understands that healthcare can be very expensive and you do your best to keep the plan’s expenses low.

2. Offer something more than the competition

If you offer longer office hours than your peers, be sure to state that in your request. If you have mid-level practitioners or an online patient portal, payors want to know this. Anything that tells this payor you make things as easy as possible for their members. List all the reasons why you are the best.

3. Evaluate your surrounding area

Ask yourself: How many other providers of the same specialty are there in a 5-mile radius? Do they all offer the same conveniences as you? What makes you special compared to the other physicians in the area? Try to stand out against other physicians in your target area.

4. List all of the specialized training you currently hold certificates for

If you are double board certified, be sure to say so and provide documentation showing that information. If you have state of the art medical equipment or you offer a procedure no one else does, be sure to state that. Anything and everything related to your specialized training and education should be stated. You should also document the specialized training of any staff members within your office. If you have an RN license instead of an MA license, be sure to state that as well. Get creative and essentially think of this as a resume for a job. Every little thing counts.

After obtaining all of the required information, find a reputable credentialing company who can organize this information into a complete and organized packet to submit it to targeted payors that you’d like an increase with. For rate increase requests, each payor will have specific forms they will want filled out. These payors will also want to know exactly how much of a rate increase you are requesting. Be reasonable, or your request will not even be considered.

Overall, be kind to the person who is handling your request. Remember, you’ll catch more flies with honey.


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Cynthia Young, the former CEO of STAT, is a national billing, credentialing and practice management consultant. STAT is a U.S.-based, national provider of credentialing, payor enrollment, rate negotiation, and other credentialing related services.