Watch for language concerning a payer’s ability to recoup payments, Fazio warns. If a contract does not address this topic, push for its inclusion. “You want to define a period when payers can recoup payments. They should not be able to do so indefinitely.” Payers are increasingly engaging third-party entities to audit claims and payment records, he adds. “These entities are incentivized to find recoupment opportunities. Limiting their timeframe is in your interest.”
Majewski checks contracts for language speaking to implant payments. “We fight for our contracts to include implant carve outs. Our supply costs have gone up while reimbursement has moved in the opposite direction. If you are not getting paid enough to at least cover implant costs, you are probably going to lose a lot of money.”
Another proposal to look for concerns payment for procedures not on Medicare’s ASC Covered Procedures List. Commercial payers had typically proposed payment for these procedures as a percentage of charges, Fazio says. This formula could make performing the procedures financially worthwhile for an ASC. But more recently, he says, payers are including language defining a default payment rate for these procedures, with the rate too low to make many of the procedures profitable. “Some contracts have language that stipulates paying for noncovered procedures through both of these formulas, which is problematic,” Fazio says. “Proposals should be clear about how you are going to be paid.”
Considering what is at stake with payer contracts, Majewski always has them reviewed by her ASC’s legal counsel. “It is difficult to understand all the language and provisions. We want to know what we are agreeing to in a contract before we sign it.”