DENIALS & APPEALS
Do you need help to optimize your contracted reimbursement?
Mercury Advisory Group experts share insights, analysis and perspectives for hospitals, clinics, pharma and device manufacturers, lab and imaging centers, rehab centers and integrated health systems. In reading these articles and listening to podcasts from our experts, you'll discover a wondrous path to a new world of contracted reimbursement spanning almost 35 years of trends, experiences, and case examples of reimbursements using mandated fee schedules, discounted fee for service, per diem rates, DRG rates, RBRVS, capitation, sub-capitation, pay for performance (P4P), bundled case rates, shared risk arrangements, MIPS, MACRA, and value-based reimbursement.
Featured article - Contracted Reimbursement
Maria Todd reviews the variety of situations where a seemingly otherwise valid contract could be unenforceable by the courts or arbiters in binding arbitration.
More Articles & Media
Avoid these Costly Oversights in Your Managed Care Contracts
Calls we get from physicians, dentists, orthotics and prosthetics providers, and even psychotherapists, labs and medical supply companies, vary from wanting swift and decisive action to improve their contracts or give notice of termination, to other calls that come from providers who signed on the dotted line before reviewing their payor contracts carefully and are now afraid to "rock the boat".
New Managed Care Acronym: ABCB - Avoid Bungled Capitation-payment Blunders
While many current contract analysts are new to capitation and value-based reimbursement, Maria Todd shares lessons learned from more than 25 years of capitation rate negotiations from her work with over 400 IPAS, PHOs, MSOs, ACOS and HMO provider relations manager work experience.
Managed Care Podcasts on BlogTalkRadio
US Hospitals Investigate Inbound /Domestic Medical Tourism Service Lines
Maria Todd reviews some of the ways that US hospitals can launch a medical tourism program at their facility.
Case Rates: How to Define Them in Third-party Payer Agreements
Most providers leave themselves exposed to financial risk of loss because of the ambiguities they leave unspecified in case rate price proposals. Here's how to mitigate that risk with better definitions and specific inclusions and exclusions in the Episode of Care.
Mercury Advisory Group Shares on Sound Cloud and BlogTalkRadio
Virtual Managed Care Lunch & Learn Webinars
The Virtual Managed Care Lunch and Learn Webinar is a new benefit for clients, colleagues and followers of Maria Todd and the Mercury Advisory Group. In most sessions, Maria Todd presents the webinar giving a 20 minute presentation on a short topic of interest to those that are involved in healthcare revenue cycle and managed care analysis. The presentation is immediately followed by a live Q&A session, so plan to have access to a telephone, microphone or to enter your question as a "chat" message to the presenter. On occasion, Maria invites thought leaders in managed care to present a session on a topic in which they specialize or lead the industry. All sessions are free to listen in, so gather your team in the break room or conference room, grab a snack and a beverage and join us!
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Maria Todd is the Managed Care Lunch and Learn Webinar Presenter
Maria K Todd, MHA PhD
The Managed Care Contracting Handbook
The Managed Care Contracting Handbook, 2nd ed
The Physician Employment Contract Handbook
The Physician Employment Contract Handbook, 2nd ed
IPA, PHO, MSO Development Strategies
Physician Integration & Alignment: IPA, PHO, MSO, ACOs and Beyond
Health law paralegal, certified mediator, hands-on experience as a TPA owner / operator, HMO Provider Relations Coordinator, hospital business office manager, multispecialty group practice administrator, vascular imaging lab COO, developer of more than 400 IPAs, PHOs MSOs and ACOs, and ASC administrator.
Maria Todd is an international healthcare business expert who helps healthcare providers on five continents negotiate with insurers, TPAs and employers, union health and welfare groups and governments that sponsor self-funded health benefit plans or self insure.
Maria brings a vast array of experience including provider and payer side negotiations, clinical experience as a surgical nurse, dispute resolution as a certified mediator and the research and due diligence analysis from work as a health law paralegal. She's helped negotiate contracts with every type of healthcare provider in every size organization. Her contracts archive includes actual agreements from over 4000 clients spanning more than 35 years of work experience. She's mastered multi-cultural negotiation tactics and strategy. She is familiar with many of the obscure state laws, federal laws, and regulations that tend to be overlooked or missed to the provider's detriment and disadvantaged by both health plan provider relations representatives and providers alike.
PERSPECTIVES: MultiCultural Negotiation
MultiCultural Contract Negotiation and Business Transactions
Values in the workplace are influenced by culture, which Professor Geert Hofstede defines as the collective programming of the mind distinguishing the members of one group or category of people from others. He and his colleagues advance a system that is comprised of 6 dimensions of national culture, including:
- Power distance
- Individualism vs Collectivism
- Masculinity vs Femininity
- Uncertainty Avoidance Index
- Long Term Orientation
- Indulgence vs Restraint
When we negotiate with others for jobs, contracted reimbursement, or even to champion causes and organizational change, we must take into consideration the multicultural "baggage" that each of us bring to the table. To negotiate in a vacuum without acknowledgement of the multicultural differences ingrained in our personalities is to start the entire process at a disadvantage. Doing so can easily derail the entire process of mutually beneficial negotiation and turn it into an unintentional but almost visceral dislike of the other party. Understand how this translates to strategy, context and culture and you'll feel more confident in your negotiation skills and preparation.
Strategy is comprised of everything that will give guidance to management in order to realise what it wants, such as mission, vision, core values, purpose and objectives.
The context in which an organization operates will limit the options management has to come up with their optimal culture of choice. Thus, if central government has imposed many of laws and directives on a particular sector, for example in the case of pharmaceuticals, pharmaceutical companies cannot score higher on Dimension D2: Internally versus Externally driven than between 50 to 60. The exception is when management of such companies are up for a confrontation with government regulation or they are able to bend the rules.
Unless stated otherwise, we mean organizational culture when using the word culture. In addition to organizational culture one can distinguish many other types of cultures, such as national cultures, regional cultures and professional cultures.
Learn More About Multicultural Negotiation
The Hofstede Multi-Focus Model on Organizational Culture
Organizational Culture is the way in which the members of an organization relate to each other, their work, and the outside world in comparison to other organizations. Your organizational culture can either enable or hinder your strategy in many ways. Organizational culture, according to Hofstede, consists of eight dimensions:
- D1 Means-oriented vs. goal-oriented
- D2 Internally driven vs. externally driven
- D3 Easy-going work discipline vs. strict work discipline
- D4 Local vs. professional
- D5 Open system vs. closed system
- D6 Employee-oriented vs. work-oriented
- D7 Degree of acceptance of leadership style
- D8 Degree of identification with your organization
When negotiating with a health plan, an employer' Plan Administrator, a TPA, or a PPO representative, or a case manager negotiating for a "spot" discount on a one off basis, you must first determine the culture of that organization as it exists in the market. This is easier at the local or regional level because the culture of the market influences the organizational culture. Dealing at a national level is far more complicated because the fine tuning for the local market is blurred or altogether absent. One must take into account the market culture, which influences the organization, and then the organizational culture which influences the representative negotiator. Then one must refine the personal culture of the representative that he or she brings to the negotiation table, which is influenced, at least subliminally by the dominant influencing national culture of the negotiator. This analysis helps us to prepare to meet our negotiation opponent and strike the best possible deal.
The Hofstede Multi-focus Model is a strategic tool aimed at helping organisations by visualising four conditions:
- The actual culture in an organization
- Possible external restrictions limiting the optimal organizational culture (legal, financial, data, board members and shareholders, other providers, members and subscribers)
- The condition for change
- Hidden pains
Learn more about the organizational culture model with a handy online application (It's free and fun to use!)