Reimbursement specialists should be consulted to help develop a reimbursement model that carefully accounts for operational costs. Stop-loss is a contract term that limits a provider's obligation to provide services once a negotiated level of services or costs has been exceeded. It is important to include stop-loss provisions in a contract to limit total risk. The intent of stop-loss provisions is to limit a facility's or a program's risk of losing money. Exclusions are services that are not included in the pricing agreement and that are paid for by the MCO separately.
Exclusions are imperative in terms of limiting a pain facility's financial risk.
Providers should outline items or services that are atypical or very costly during a patient's treatment course. These should then be submitted for exclusions to the provider's contract. It is prudent to always consider exclusions, even when negotiating for an individual patient's treatment authorization. Some pain facilities have, in the past, garnered a negative reputation by accepting every patient. Most contracts include this provision in favor of the MCO but do not have such a clause for providers.