Family planning providers will need to become proficient at working with health insurance plans to stay viable in a rapidly changing health care system, according to a new Guttmacher Institute report. Although doing so will require a significant investment of providers' staff time and resources to create the necessary expertise and infrastructure, it will ultimately strengthen their ability to provide much-needed services in their communities.
"In order to retain their client base, and be reimbursed for the care they provide, family planning providers are finding they need to be included in health plan networks," says Rachel Benson Gold, one of the report's authors. "Our report details the many considerations, from laying groundwork internally to understanding the marketplace in which they operate, that providers will need to address."
The Guttmacher report is based in large part on discussions by an expert panel in November 2011 and compiles the lessons learned by family planning agencies that have successfully participated in plan networks serving both Medicaid and commercial enrollees. To negotiate and successfully operate under a favorable contract with a health plan, providers should consider taking the following steps:
- assess their own strengths and weaknesses, including taking stock of needed skills and capabilities in areas like health IT, electronic billing, coding and claims processing, as well as understanding the true underlying cost of each of the services they provide to clients so they can seek adequate reimbursement;
- understand the marketplace, including helping plans understand the value that family planning providers can bring to their networks and learning what is, and is not, negotiable during contract talks; and
- work successfully with plans, including addressing a wide variety of technical issues, such as ensuring that clinicians are appropriately credentialed and that they and their front-line staff understand how to properly bill insurance.
"Making the transition to working with health plans, especially acquiring sufficient expertise and infrastructure, will certainly be challenging for some providers," says Gold. "At the same time, it is encouraging to see that many family planning clinics have already successfully completed this process, learning valuable lessons along the way on which others can now draw."
The report suggests a number of steps that the Title X program and the Office of Population Affairs can take to advance this process, including training family planning programs to identify and customize health information technology systems that best meet their needs, and providing technical assistance on key skills that agencies will need.
"As a whole, the system has a long way to go," says Gold. "Only 40% of family planning centers had a contract with a health plan to provide contraceptive services to Medicaid enrollees in 2010, and only 33% of centers had a contract with a private plan. These percentages will need to increase quickly if we are to preserve a viable and vibrant national network of family planning providers."
Click here to read "Working Successfully with Health Plans: An Imperative for Family Planning Centers," by Rachel Benson Gold and Adam Sonfield.
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