HealthLink’s Provider Contracting Team
Takes Bold Steps to Protect Clients
HealthLink’s Contracting Team is actively leveraging HealthLink market position to protect the customer. The team is taking bold
steps with provider contract language to protect clients and their health plan enrollees, including the revision of Fee Schedule
language to support Best Practices. These revisions allow HealthLink clients to better manage rising health care costs.
Fee Schedule Best Practices Contract Revisions
Contract Revision
Summary
Evaluation and Management Codes
Contracts increase E&M reimbursement and decrease specialist rates to encourage more thorough care by PCPs.
Place of Service Pricing
Contracts higher reimbursement for procedures performed in the office rather than in a facility promoting cost consciousness
and helps address the issue of inappropriate health care spending.
Reimbursement for Conscious
Sedation vs. Anesthesiologist
Services
Contracts promote use of conscious sedation when appropriate in order to eliminate unnecessary anesthesiologist charges.
Coverage for Vaccines and
Injectibles
Coverage for vaccines and injectibles administered in the office to promote member compliance with preventive health
recommendations.
Same Allowable for Related/
Similar Procedures
Contracts eliminate financial incentives for higher reimbursement procedures and prevents over-utilization of services
(example: same allowable for vaginal and C-section deliveries).
Four Walls Rate Structure
Contracts ensure rates do not increase automatically if provider moves or consolidates. Includes facilities that are purchased
by providers after they have contracted with HealthLink.
Never Events and Hospital
Acquired Conditions Exclusions
Contracts stipulate that HealthLink and its clients will never pay for events that resulted from hospital error or for nondiagnosis related conditions that the patient acquired while in the hospital.
Transparency
Contracts allow HealthLink to publish rates, keeping facilities and physicians accountable for fees charged.
Charge Master Protection
HealthLink and its clients are not susceptible to providers increasing their charges and require providers to report
Chargemaster rate increases on an annual basis. If their increases are in excess of predefined limits then the contract rates
are adjusted to neutralize the impact of the increases above the limit.
DRG Case Rates and
Lesser of Language
Protects HealthLink and its clients from being overcharged for hospital stays when the patient is released early.
Stop Loss Carve Outs
Prevents hospitals from forcing claims to hit stop loss threshold by requiring them to separate costs associated with
procedures from costs associated with medical devices (example: a $75,000 pacemaker will always exceed the stop loss
threshold unless the cost to implant the devise is carved out of the stop loss threshold amount).
This aggressive stance on the part of HealthLink’s Contracting Team has been in play throughout 2012, with numerous success
stories in contract negotiation. In general, HealthLink kept 2012 renewal rates below 5%. HealthLink will continue Best Practice
contracting in 2013. For additional information about any HealthLink programs, please email Mark Haegele, Director of Sales, at
[email protected] or call (314) 925-6310.
We look forward to serving you and your client groups!
HealthLink , Inc., is an Illinois corporation. HealthLink, Inc. is an organizer of independently
contracted provider networks, which it makes available by contract to a variety of payors
of health benefits, including insurers, third party administrators or employers. HealthLink
has no control or right of control over the professional, medical judgment of contracted
providers, and is not liable for any acts or failures to act, by contracted providers.
HealthLink, Inc. is not an insurance company and has no liability for benefits under
benefit plans offered or administered by payors. HealthLink is a registered trademark of
HealthLink, Inc. and a separately incorporated and capitalized subsidiary of WellPoint, Inc.
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BROKER-BULLETIN 3-13
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