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Payer Policies and Procedures

There are two main parts of contracts Health Partners manages for providers: 

  • Contract negotiation
  • Contract management

Contract mediation

Health Partners offers contract management for more than 20 payers.  Every year there are usually 1-2 new contract to complete and 1-2 old contracts that will need to be reviewed and renewed.  For larger payers, when we review a contract that process can take 4-6 month to complete as we go back and forth with the payer in an effort to get the best contract language for providers and rates based upon what the providers have communicated to us.  

The language negotiation is the largest part of the contract.  Through negotiation of the language, we focus on things such as timely file, how to handle claim disputes, audits, ability to terminate as well as the language surrounding reimbursement and countless other topics in order to best position providers to maximize their reimbursement.  

The determination of rates begins with a review by Health Partners but is decided upon only by the providers.  Providers will communicate to Health Partners yearly rates they are willing to accept based upon the codes they bill.  When we complete the language negotiations with a payer we then use the messenger model to message out the contracts to members of Health Partners to accept, reject or counter offer for each contract.  

Contract management

Health Partners plays a role not only in the negotiation of the contracts, but in the management of each contract by assisting in holding payers accountable to the terms agreed upon.  We do this through claims and policy assistance for members.
Claim assistance - Claims that providers need assistance with that qualify for Health Partner’s intervening are identified by one of three criteria:  1) high dollar claims (amount?)  2) claims that are systemic in nature (ones that may be for a smaller dollar amount but are very common codes used by a clinic that will result in a large financial loss if the problem is not addressed and fixed) and 3) when a provider/clinic has tried but has not received the attention needed from a payer (as set in the payer’s claim dispute process) to resolve the issue.  Assistance from Health Partners begins when a provider/clinic reaches out to us through completion of a Health Partner’s Claim Resolution form.

Policy assistance – Most of the contracts with payers are set on a one or two year length.  During that time, payers frequently introduce policies that may affect processes and even reimbursement of the provider/clinic.  Every contract has different language detailing how and when this is appropriate by a payer.  Health Partners role is to help providers interpret new policies that payers implement and, as the contract allows, advocate on behalf of providers to dispute such a policy.  Health Partners encourages providers to read the monthly/quarterly newsletters payers put out where such polices are commonly announced.  

Links to all of the payers websites that includes newsletters, policies and authorization information can be found on Health Partners website.  

Contact for contracts:  Matt Taylor and Kyle Barlow