It is important to review and evaluate your fee schedules annually, preferably at the beginning or the mid-point of each year in order to take full financial advantage of the contractual provisions affecting your practice. The purpose for entering into these types of discussions is to generate more money for your practice. Even if a health plan wanted to be flexible, it is often difficult for these entities to do so and accordingly, reluctance prevails. Their systems, methodologies, and administration are set up to facilitate consistency for administrative efficiency. If a physician proposes a change in the participation agreement, he or she will be told that it can't be done because the Department of Health approved the participation agreement.
Physicians know the routine and the drill.
Consider proposing to the health plan's medical director that your practice is interested in entering into a contract with the health plan, under a separate arrangement from the existing participation agreements, for adherence to clinical guidelines. Should the health plan show an interest, consider requesting for the following as it relates to this concept. If you have a smaller practice, ask the health plan's medical director what is the most prevalent condition affecting the health plan's membership and choose a corresponding guideline. For simplicity sake, propose the use of two of the health plan's clinical guidelines. It is reasonable to request the opportunity to review the proposed guidelines with the physicians within your practice for possible modifications prior to implementation.