Managed care companies come to the negotiation table with highly skilled negotiators who are trained to make sure that physicians are paid as little as possible for the services they provide. They know that physicians and practice managers simply don’t have the time to fully understand the intricacies of the contracts they are signing. At Fulcrum Strategies, our goal is to help physicians to succeed in the business of healthcare. We can determine if you are getting fairly reimbursed from the payers, or if there is potential for better rates and contract language. Our team, skilled in contract negotiation strategies, will handle all of your managed care contract negotiations. You maintain complete decision-making control throughout the entire process while we do all of the work.
Before we take on a new client, we want to get a realistic picture of the group’s situation. We look at things that could help or hurt future negotiations – for example; local competition, any unique aspects of the group, and contract language and rates. If we don’t think we can help a particular practice, we don’t want to take their money. To determine if we can help, we will perform a complimentary data analysis of your contract rates. We will ask you to provide us with a utilization report of your top codes with volume and fee by payer, along with the contracts themselves. From the hard data, and our knowledge of the various payers’ practices, we will normalize your contracts to a single year of Medicare so they can be compared accurately to each other, and allow us to identify which contracts can be improved. From there, we will determine how much money could be available if you were to engage Fulcrum Strategies to renegotiate your contracts.
“You don’t get what you deserve – you get what you negotiate!”
When a group decides to become a client, we’ll draft up Consulting Agreement for your review. Once signed, we begin the negotiation process. We use the previous analysis we performed to organize a “plan of attack.” We recommend which contracts should be negotiated first and predict what the likely outcomes will be. This is a collaborative process and we always defer to the client's wishes. As negotiations proceed, the client is updated as often as they wish. Once the documents are finalized, we keep images of all contracts in our database for future reference. For our clients’ peace of mind, we maintain a calendar of all contractual renewals for as long as the client remains with us.
Alternative Payment Negotiations
The healthcare landscape is changing – especially with regard to how physicians are paid and who pays them. Today, healthcare professionals are being bombarded with new terms like: Accountable Care Organizations, Patient Centered Medical Home, Tiered Networks, Episode of Care, Shared Savings and Pay for Performance, to name a few. Physicians and medical practice managers who don’t fully understand these new payment models could unknowingly sign unfavorable contracts and incur substantial revenue losses.
Now more than ever, you need a trusted ally at your side – someone who has your best interest in mind and who understands these new approaches to reimbursement methods. Fulcrum Strategies is uniquely suited to be your best advocate in these difficult and complex negotiations. At Fulcrum Strategies, our team of former insurance professionals will make sure you are protected before you enter into one of these new agreements. We can help you to understand the frequent changes that are taking place, how they will impact your practice, and how these changes can be tailored to actually benefit your practice.
Contact us today to discuss how we can help with contract negotiation services.
The United States military develops and maintains plans for every possible situation and contingency. The hope is that they never have to act on those plans, but if something does happen, they will be prepared and can immediately respond by pulling out strategic and tactical plans that were uniquely developed for the event at hand. In contrast, very few medical groups have anything that looks like a strategic plan. As a matter of fact, most medical groups have only a fundamental understanding of their business, let alone the threats and opportunities that could positively or negatively impact their business.
Fulcrum Strategies offers a menu of Strategic Planning services specifically designed for medical practices. Our services can help you gain a better understanding of your business and how to use that information to develop short- and long-term strategic plans.
Some of the services we offer are:
It’s easy to let your charge schedule sit forgotten on a shelf while you chase your contracted commercial rates from negotiation to negotiation. It’s important, though, to keep an eye on what your practice charges because that information goes out on every claim, is visible to patients, and is always compared to your contracted rates when it’s time for an insurer to pay your claims. Charge too little and otherwise higher-paying services will be capped at that lower rate. Charge too much and you start to look “greedy.” With charges at very large multiples of Medicare, you potentially open yourself up for public criticism from commercial payers and patients. Why charge 800% of Medicare if you accept contracted rates at 130%?
Fulcrum Strategies can help you keep your chargemasters up to date. We’ll review your fees, comparing them code-by-code to Medicare, and give you specific feedback on which charges should go up and which can come down. We can also compare your charges to your commercial contracts to ensure you’re charging enough to get paid the rates you worked for in the first place. All we need is your current list of charges, by CPT code, in an electronic format, and we’ll take it from there.
Payer Mix Evaluation
It seems elementary, but your payer mix can have serious implications for your future. How many of you have practice management systems that give you a good breakdown of where your revenue is coming? And how many of you take the time to read them? Fulcrum Strategies can help you build a payer mix if your own system doesn’t produce one for you. After that, we can shine the light on potential pitfalls that stem from upcoming changes to Medicare or proposals from commercial payers. In 2023, it’s highly likely that the final rule from CMS will reduce Medicare payments across the board. What percent of your total revenue comes from Medicare? Fifty percent? How much does that equate to per partner? Do you have commercial contracts based on “current year” Medicare methodology? Which ones, and for how much of your remaining revenue do those contracts account? How much impact does one seemingly simple change have on your financial wellbeing? Fulcrum can help you spot the vulnerabilities in payer mix and help you plan for upcoming changes.
Incorporating all the elements we’ve discussed separately; financial forecasting is essential to weathering changes and navigating a course to a solid financial future. Fulcrum Strategies can take the information we’ve used to develop your payer mix, evaluate your chargemaster and commercial contracts, your physician compensation program, fixed and variable practice costs, and use that mountain of information to envision where you could be headed. Current plans can be analyzed for performance and new ones developed using future financial impact as a guide.
This type of analysis requires a great deal of information, and like most work of this kind, is sensitive to the quality of that information. To begin any kind of future planning, Fulcrum will need:
- Accurate practice utilization, by payer, including code, modifier, units, charges, insurance, and patient payments
- Fee schedules and/or contracts from your commercial payers that cover your entire range of procedures. Contracts must contain specific enough language to build accurate fee schedules, if no schedules are provided
- As much internal practice data as you can gather, regarding your internal cost structure
These models, once complete, can be used repeatedly to test the effects of different changes and identify opportunities for efficiency.
What if Medicare cuts their conversion factor in 2023?
What if Blue Cross requires me to use their specialty pharmacy rather than allowing me to buy and bill?
What if I terminate United and they access my Multiplan contract for their members?
The business of modern medicine is filled with “what if” moments. Can you answer the questions that arise? Can you tell what a shift in membership or a change in RVUs will do to your revenue? Fulcrum Strategies can help you answer those questions. When it comes to potential changes in revenue, using the same information we would use for contract rate or payer mix analysis, Fulcrum can help you answer any number of “what if” questions. Our decades of industry experience have taught us the questions to ask when our clients think about making changes to their contracts, Medicare, or when the commercial payers start talking about changing rates. Let us guide you through the process of determining what effects these changes could have on your practice.
Physician Compensation Evaluation
One of the most controversial and divisive topics for any medical group is partner compensation. How the money is split among partners can either propel a group in the right direction or cause internal strife and eventually result in the destruction of the group. A well-constructed physician compensation model rewards the behaviors the group wants, supports your strategic plan, and is viewed as fair by all partners. Achieving this trifecta is not easy.
Fulcrum can review your current model and provide recommendations for potential changes to the model. We can also run several “what if” scenarios to show what changes to the model would do to current partner compensation levels. Finally, we can take your compensation model and use it to help support future strategic decisions.
Payer Contract Review
When was the last time you reviewed your payer contracts? Do you know how your payer agreements compare on a weighted average percentage of Medicare? Do you know which services or service lines provide better reimbursement for your practice? Are you sure that the charge you bill for each of the services you provide is higher than the allowable amount on all your contracts?
If you can’t answer all these questions, or if your answer is “no” to any of them, then you really need to do a full review of all your payer agreements. Fulcrum Strategies can evaluate all your payer contracts and provide your practice with the following items:
- Summary document of your contracts, reimbursement rates and major terms and conditions of each agreement
- Detailed analysis and fee schedule for each agreement
- Billed charges checked against payer allowable amounts
- Organized electronic copies of current agreements and amendments
- Recommendation for future contract negotiations or renegotiations
- Comparison of your rates to regional or national rate averages
Strategic Plan Development
Every business, and as such, every medical group, should have a short- and long-term strategic plan. This plan should be reviewed every 2 to 3 years and adjusted accordingly. Part of this strategic plan should be an analysis of the practice’s strengths and weaknesses. The strategic plan should identify opportunities and threats. The plan should also contain a financial forecasting tool that can be used to evaluate strategic options and measure the success or failure of executed tactics against projected outcomes. Failure to have a well-thought-out strategic plan, the tools to evaluate strategic options, and the ability to measure performance, leaves your practice’s success and hope for a brighter future up to chance. Hope is not a strategy.
Fulcrum can help your practice develop an individualized strategic plan, with all the tools necessary to make sure you are successful in executing your plan. With Fulcrum, your practice can be successful in these ever changing and challenging times.
Mergers and Acquisitions
At some point most independent medical practices are faced with the question of merging, acquiring, or being acquired by another group or a hospital system. During these times, and given the importance of these decisions, it is helpful to have someone in your corner who can provide honest advice, guidance, evaluation, and analysis for your group. Fulcrum Strategies has extensive experience navigating these confusing waters and can help you make the best decision for your group and the situation at hand.
We offer consulting and assistance in several areas:
- Black Box analysis and revenue pro-forma development for potential mergers
- Evaluation of purchase offers
- Strategic evaluation of payer reaction to merger opportunities
- Evaluation of current payer contracts that could impact merger timing and effectiveness
- Representation and assistance in deal negotiation
A “Black Box” analysis is one of the first major steps that guides groups from the theoretical “what if we did this” stage, and leads them down the path of merger or acquisition. Essentially, it answers the question “will this be good for my group?” Fulcrum will gather data and contract documents from both groups and produce a comparison that indicates whether it’s financially advantageous for one group to be acquired by another. To perform the analysis, we would need:
- Utilization from the group to be acquired. If the groups are considering an “even” merger, utilization data would be needed for both practices to determine whose contracts would be the best for the combined entity.
- Contracts or fee schedules from both groups to produce a weighted review of your financial terms with your commercial payers.
Once the analyses have been completed, both parties to the proceedings will be presented with a statement indicating what the net revenue change would be if one group came under the other’s contracts. All revenue is combined to form a single number to prevent violating any of the individual contract’s confidentiality clauses.
Further items for consideration are the assignment clauses from your contracts, hospital stipends if applicable, and opportunities for increased operational efficiency from common infrastructure.
- Most commercial contracts contain language that prevents practices from simply absorbing another group and adding them to their (higher paying) contracts. The insurance company must agree to add the new physicians to the contract roster of the existing group – and most of the time they will not do so. The newly added physicians will remain on their existing contract with that payer, if they have one, even after their old organization has ceased to exist. Not until that old contract is eligible for termination do the new doctors have an opportunity to be joined to the higher-paying contracts of their new employers. And, the payers don’t even have to allow it then. They can technically leave those new physicians as non-participating after they terminate their old agreement. It doesn’t happen often, but it’s a possibility that does sometimes happen.
- For hospital-based groups, any stipends paid to them need to be included in the black box analysis. If the two have very different levels of financial support from their hospital, transferring from one practice to another could cost more than is made up for by the higher-paying commercial contracts.
- To the extent possible, infrastructure should be included in your considerations, since it forms the backbone of your daily functioning as a practice. Especially easy, or difficult, integration should be reviewed. New licenses and/or user fees for the acquired group could undo a slim advantage in contract rates.
Hospital Based Physician Consulting
Hospital based physicians face a very uncertain future. No Surprises legislation threatened to hand your financial future over to payers who are incentivized to reduce your practice’s revenue to bolster their own profits. The original law that was finally passed offered physicians a reasonable path to keep predatory insurance companies from simply offering terrible rates and walking away, knowing doctors had no recourse. The most recent interim final ruling, produced by the Secretary of Health and Human Services, reverses that progress and once again delivers the futures of hospital-based physicians into the hands of the payers.
- We can help you analyze and explore options contained within your hospital contracts, drawing upon our decades of experience working with physicians, facilities, and the payers.
- Fulcrum will keep you up to date – as up to date as possible – with the changes coming from Washington and how they’re likely to affect your practice. Every week seems to bring a new development or reinterpretation, all of them with ramifications for your practice.
- We can analyze rates offered by any payers you may not be contracted with and compare them to your other agreements. We can even compare potential non-par fees to your current agreements and give you a detailed “what if” analysis for any payer who may be at risk of termination.
- Fulcrum can evaluate the impact this new law could have on your revenue and help you negotiate with your hospital or other entities to help offset this revenue reduction.
Fulcrum Strategies can help you navigate through this process as it evolves and position yourself for the best possible outcome.
Hospital Contract Negotiation
Managed care companies come to the table with highly skilled negotiators, dedicated to facility contracting, who are trained to make sure hospitals are paid as little as possible for the services they provide. They know many hospital administrators simply don’t have the time or expertise to fully understand the intricacies of the contracts they’re signing. At Fulcrum Strategies, our goal is to help hospitals succeed in the business of healthcare. We can determine if you are getting fairly reimbursed from the payers, or if there is potential for better rates and contract language. Our team, skilled in contract negotiation strategies, will handle all your managed care contract negotiations. You maintain complete decision-making control throughout the entire process while we do all the work.
“You don’t get what you deserve – you get what you negotiate!”
When a hospital decides to become a client, we’ll draft a Consulting Agreement for your review. Once signed, we’ll begin the contracting process. We will quickly develop and organize a plan of attack by recommending which contracts should be negotiated first and predict what the likely outcomes will be. This is a collaborative process, and we always defer to the client's wishes. As negotiations proceed, the client is updated as often as they wish. Once the documents are finalized, we keep images of all contracts in our database for future reference. For our clients’ peace of mind, we maintain a calendar of all contractual renewals for as long as the client remains with us.
Alternative Payment Negotiations
The healthcare landscape is changing – especially regarding how hospitals are paid and who pays them. Today, healthcare facilities are being bombarded with new terms like: Accountable Care Organizations, Patient Centered Medical Home, Tiered Networks, Episode of Care, Bundles, Shared Savings and Pay for Performance, to name a few. Hospitals that don’t fully understand these new payment models could unknowingly sign unfavorable contracts and incur substantial revenue losses.
Now more than ever, you need a trusted ally at your side – someone who has your best interest in mind and who understands these new approaches to reimbursement methods. Fulcrum Strategies is uniquely suited to be your best advocate in these difficult and complex negotiations. At Fulcrum Strategies, our team of former insurance professionals will make sure you are protected before you enter into one of these new agreements. We can help you to understand the frequent changes that are taking place, how they will impact your facility, and how these changes can be tailored to benefit your organization.
Contact us today to discuss how we can help with contract negotiation services.
ASC Startup Consulting
Starting a new ambulatory surgery center? Fulcrum Strategies is well equipped to help you navigate what could be an arduous journey if you’re unprepared. Adding a surgery center to your existing physician practice is a serious undertaking that can have a profound impact on your organization. It could increase your leverage with the payers, give your patients a more seamless experience, and hopefully bolster your bottom line with improved revenue – but do you know how to get the best results?
This is where Fulcrum can help.
A successful resolution starts with a smart beginning. When considering adding a surgery center to your practice, there are some important questions you might want to ask yourself. For example, did you do a proforma? Was it reasonable, grounded in market standards and solid data? Do you know what services you’ll be able to transfer from existing hospital ORs and into your own center? Do you have a clear understanding of your costs and the rates you’ll need from the payers to make your new ASC profitable? Are you ready to negotiate with all the major insurance companies at the same time? Do you have a realistic plan for how long it will take to start performing paid procedures?
We can help you with each of these steps as you progress towards opening day. Fulcrum is experienced, not only in initial and renewal contract negotiation with managed care payers, but we also provide advice on realistic rate expectations, which allows us to produce financial modeling using your own utilization experience.
The additional capability and revenue that comes with opening your own ASC will have your practice eagerly anticipating the day you can start scheduling patients. However, if the requisite steps are rushed or missed, the results could be detrimental and impede progress.
Fulcrum’s team of professionals will help manage expectations and guide your staff through every stage of change and growth. Contact Fulcrum Strategies today as you begin the process of establishing a new ambulatory surgery center. We can help you create the path that leads to a successful opening and a promising future.
Speaking and Seminars
Fulcrum Strategies offers professional speaking services for conferences, meetings and more. Ron Howrigon has been speaking professionally since before founding Fulcrum Strategies. With 18 years of experience in the managed care industry, and an additional 19 years as a physician consultant, Ron incorporates his experience on both sides of the negotiation table into his presentations, which are informative, engaging and entertaining.
Some of the engagements in our speakers' portfolios include:
- Medical Group Management Association (MGMA)
- Radiology Business Managers Association (RBMA)
- Ohio Association of Rheumatology (OAR)
- Ohio State Medical Society (OSMA)
- Association of Community Cancer Centers (ACCC)
- American College of Emergency Physicians (ACEP)
- Coalition of Hematology and Oncology Practices (CHOP)
- Cancer Care Business Summit
- Bayer Pharmaceutical / ICPME - Business IQ
- American Association of Orthopedic Executives (AAOE)
- American Healthcare Radiology Administrators (AHRA)
- Southern Oncology Association of Practices (SOAP)
- Indiana Medical Group Managers Association (IMGMA)
- Indiana Association of Orthopedic Executives (IAOE)
- Indiana Oncology Society (IOS)
- Georgia Association of Orthopedic Executives (GAOE)
- Professional Association of Healthcare Office Management (PAHCOM)
- Association of Otolaryngology Administrators (AOA)
- Medical Office Managers Society of South Jersey
- Medical Group Managers Association (MGMA)
- Southern Association of Therapeutic Radiation Oncology (SATRO)
- The Arizona Clinical Oncology Society (TACOS)
Ascent - Administrator Support Community for ENT
- EDPMA - Emergency Department Practice Management Association
President and Founder
Here is a list of our current speaking topics:
- Dancing with the Devil: Negotiating with Managed Care Companies
- Healthcare Evolution...or Revolution? Exploring the Shift from Fee for Service to Value-Based Approaches
- Patient-Centered Healthcare: Improving the Patient Experience
- Reimbursement Trends in a Post-Healthcare-Reform World
- Accountable Care Organizations
- Flatlining: How Health Care Could Kill the U.S. Economy and How We Can Stop it
- The Future of Health Care. What Will it Look Like in Five Years?
- Population Health Management
- To Be Par or Not to Be Par, That Is The Question
- Strategic and Tactical Practice Management
- Physicians vs. Managed Care
- Pay-for-Performance and Tiered Networks
- Big Pharma and PBMs: How it all Works and Who are the Winners and Losers
- Improving Patient Experience in Patient-Centered Health Care
Here’s what others are saying about Ron Howrigon and his presentations:
"Ron Howrigon has presented at the ACEP Reimbursement Conference for the past three years, earning exceptional evaluations. He is an excellent speaker, offering the payer side perspective in contract negotiations that is very helpful for emergency physicians in understanding that process." David McKenzie, Reimbursement Director, American College of Emergency Physicians
Read more on our Testimonials page