A true story of payer negotiations

Payer negotiations are like David confronting Goliath. Physicians, whether in small practices or employed by hospitals, face a daunting challenge when trying to get a payer to approve a medication, procedure or imaging study. It is not possible to negotiate approval with every payer; however, you can pick those that are most egregious, delinquent in payment or not compensating for services performed that deserve compensation.

Let me share one success story demonstrating how to navigate the negotiation process. I was an early adopter of a minimally invasive procedure for treating benign prostatic hyperplasia. The standard of care was hospital admission and surgical ablation of the obstruction to urine flow. The cost of the hospital procedure was $25,000 to $35,000. The patient was in the hospital for two to three days, wore a catheter for another five to seven days, and resumed normal activities, lifting heavy objects, sports and sexual activity in four to six weeks. The minimally invasive procedure, or UroLift, was done in the office under local anesthesia, and the patient had a catheter for a day or less. The patient could resume all normal activities in 10 to 14 days. When patients were given the option of hospitalization and surgery versus an office procedure, 100% opted for the minimally invasive procedure.

First, I found the decision maker (bean counter) with some effort. I explained the minimally invasive procedure’s economics, patient preference and outcomes. I sent them articles from the medical literature that confirmed the office procedure had outcomes equivalent to the surgical procedure. I also informed them that a code was available for the minimally invasive procedure. I also submitted testimonials from several patients who supported the minimally invasive procedure. After several months of discussions, I received appropriate compensation for the procedure.

My takeaway message is that confronting the health care payment process can be daunting. But remember, sometimes the Davids really do beat the Goliaths!

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