Working Successfully with Health Plans: An Imperative for Family Planning Centers


Rachel Benson Gold
Adam Sonfield
Reproductive rights are under attack. Will you help us fight back with facts?

Key Points

Key Points

• The Guttmacher Institute convened a two-day expert panel meeting in November 2011 to explore challenges family planning centers face in contracting with Medicaid and private health plans—a step that is increasingly necessary for centers to remain viable as health care providers. Panel members identified several steps and principles agencies may want to keep in mind when developing relationships with health plans.

• Panel members suggested that an agency considering contracting with a health plan prepare by assessing its client profile, staff expertise and infrastructure, and by learning about the marketplace in which it operates.

• Agencies should thoroughly assess their cost of providing services, in order to be able to determine the feasibility of reimbursement rates offered by plans.

• In negotiating contracts with plans, agencies should promote their ability to help plans improve health outcomes, reduce costs and meet network adequacy and quality assurance standards.

• Agencies should also understand which key issues are open for negotiation, such as deadlines for filing claims and the scope of services covered, and which are not—notably, in most cases, reimbursement rates.

• Successfully working under a health plan contract requires training and technical expertise, such as ensuring that clinicians are appropriately credentialed and that clinicians and front-line staff understand how to properly bill insurance.

• Wherever possible, centers should consider taking advantage of economies of scale to reduce costs and leverage expertise; agencies may want to consider outsourcing some functions and collaborating with other agencies.

• Being proficient with health information technology, and especially with electronic claims processing, is essentially a prerequisite for being able to operate under health plans.

• A reorientation of priorities and a redirection of at least some current resources could significantly assist agencies funded through the Title X family planning program in making the transition to working with health plans.