The Magic of Negotiationor

Perseverance Pays Off

Federally Qualified Health Centers ∙ Joint Commission Accredited

What’s Up?• “What are they talking about?”• “Why am I listening to this?”• “I don’t have a clinic”

• But we are just like you• We take care of patients/clients• We interact with other agencies, companies and administrative

agents etc• We run into roadblocks

• Because we all have obstacles and challenges and we can learn from the lessons other people have learned

Who are we?

• David Powell Clinic is part of CommUnityCare – a Federally Qualified Health Center system in Travis County

• CommUnityCare serves around 70,000 patients annually in 24 locations

• David Powell Clinic (DPC) serves around 2,000 patients with HIV/AIDS annually in the 10 Central Texas counties:• Bastrop, Blanco, Burnet, Caldwell, Fayette, Hays, Lee,

Llano, Travis and Williamson

What’s the background?

• We are an HIV clinic – we provide primary medical and HIV care along with Psychiatry, Counseling, Social Work, Nursing, Nutrition, Class A and Clinical Pharmacy and Eligibility services

• In January 2014 we were contacted by some patients who had signed up with a large insurance plan under the marketplace• They were being told by the large insurance plan that they

had to choose a new PCP and were not allowed to keep their current PCP • Some insurance plans do not allow Infectious Disease

Specialists to be listed as Primary Care Providers (PCP)

No Way

• We asked if we could change it and the answer was…….NO

• We hear the word NO…..A LOT• No, you can’t change the wording in the contract• No, you can’t do that• No, you can’t have more money• No, your insurance doesn’t cover that• No, we don’t pay for that

NO NO NO NONO

When “No” is not a real option

• …for patients who have been with their provider for 10 years

• …as the Infectious Disease Society of America states that providers must be knowledgeable about HIV and primary care when caring for patients with HIV

• …as is not efficient to shuttle a patient between a PCP and a specialist when the disease and the treatments have so many impacts on general health

• …as it wastes dollars that can be used elsewhere

So what did we do?

• Our Provider Contracting Manager began discussions with our large insurance plan representative

• Luckily she has a good relationship with the plan’s representative

• She was in frequent contact asking for help, for updates, for any other options

Relationship Building Is Key

Never, Never, Never Give Up

• Our manager followed through with everything the Rep suggested:• Reading manuals• Responding to emails• Asking more questions• Calling the Customer Service number• Asking for “the referral form” listed in the manual

• “what referral form?”

• Our manager contacted the company multiple times over the next 2 weeks and requested that the issue be escalated to the Medical Director

• Perseverance is close to Insanity:Doing the same thing again and again and expecting a different

outcome

Next steps?

• Ask for the regulations• Ask for a supervisor or Medical Director• Persist• The response we received from the Medical

Director was:• "the SCP (specialty care provider) just needs to submit a clear,

written explanation as to why it would best serve the member for the SCP to serve as the member's PCP, along with pertinent clinical details and explicit agreement to perform all the functions expected of an HMO member's PCP”

So what did we say?• We explained who we were and the quality of care

we provided to our patients

• We provided examples of other quality criteria, outcomes measures and grant requirements that we worked with

•We cited examples where we exceeded local state or national outcomes

• We included the recommendation from the Infectious Disease Society of America stating that providers must be knowledgeable about HIV and primary care when caring for patients with HIV

What did we include?

• The Lead Provider for the David Powell Clinic sent a letter detailing:• Examples where we already met strict criteria from

other payors and grants• Joint Commission accreditation• Working towards Patient Centered Medical Home• Excepts from the Infectious Disease Society of

America’s statement:• Primary Care Key to Management of Patients with HIV

Infection• Our commitment to Primary and HIV care

Are we there yet?• We received approval from the Medical Director that

all our providers were approved to act as PCPs• The large Insurance Company is in the process of

credentialing our providers and/or updating their system• We are in daily contact with them – that’s how you

get movement • It is a long process – don’t give up • We finally have the “form” and have submitted the

first request for a Specialist to act as PCP• We are waiting to see how long it takes!

What does it mean for my Agency?

• Sell Yourself • Detail your organization’s accomplishments• “We provide services that get people into medical care and

maintain them in medical care”• Point out barriers and what you can do to help• “It is jeopardizing the patient’s medical care”

• Be persistent, be persistent, be persistent• Build relationships with other organizations• Highlight the collaborative structure locally among

healthcare providers and other ASOs• Ask for the regulations – give them feedback• Put it in writing when you have had discussions by

phone or in person• Show them what a bounty you are to the area

Like the “sailing stones” in Death Valley

• You can’t always see the work that is going on to make things move

• Sometimes it just looks like magic

• But if you work hard enough just about anything is possible

Any Questions? • Contact Information:

• Deborah Lowndes• Practice Administrator, David Powell Clinic

• Deborah.Lowndes@communitycaretx.org• Phone 512-978-9112

• Ashlee Mooneyham• Provider Contracting Manager, CommUnityCare

• Ashlee.Mooneyham@communitycaretx.org• Phone 512-978-9914

• Rhonda Ray• Grants Manager, DPC

• Rhonda.Ray@Communitycaretx.org• Phone 512-978-9125

Sometimes it is knowing the next question to ask that will get you from

No to Yes

No Nay Yay Yes