Payment & Delivery Models

Medicare Advantage value-based care contracts: What to negotiate

One in three Medicare beneficiaries is now enrolled in a Medicare Advantage (MA) plan. That’s a 71% increase since 2010, and it means there’s more at stake for you and your practice to ensure your MA plan contract is clear and fair.

The AMA offers extensive resources to help you navigate evolving physician payment and delivery models. Among these is a new resource, “Evaluating Medicare Advantage Value-Based Contracts,” which includes examples of typical and preferred contract language and details the nuances of these contractual arrangements. It also will help you negotiate contracts that have clear and fair terms and protect your right to get paid for the high-quality care your practice provides.

Related Coverage

Bargaining table success starts with these common elements

Here are some key things you need to know about negotiating terms in your Medicare Advantage contract.

What can you negotiate?

Not every term is negotiable, so it’s important for physicians to dedicate the time and resources to the ones that are, especially the ones that require physicians to take on extensive personal risk. For example, payment-related provisions should clearly explain payment methodology based on set metrics that result in higher pay if you achieve established performance levels.

Here are some other areas physicians can potentially negotiate.

Data sharing. Ask for timely access to usable data, being sure to specify in the contract the type and format in which the data will be provided. It’s not uncommon for the plan to require physicians to submit certain data within 90 days of the end of a performance period.

Termination for adverse changes. Most contracts allow an MA plan to unilaterally amend the agreement. Ideally, changes require a physician’s written consent, but plans aren’t likely to agree. To gain some level of protection, physicians should negotiate the right to terminate the contract if the plan makes amendments that adversely affect the physician, such as a drop in actual or expected payment or a rise in administrative costs.

Changes to the value-based payment methodology. Allowing some changes in value-based payment could help physicians; for example, eliminating quality measures that no longer apply to the care a physician provides. But you should ensure that measures can’t be added, deleted or significantly altered without both parties agreeing.

Fees earned during the contract term. Because payments can lag and may not be received before a contract expires, physicians should strike language that requires them to be a participating provider on the date of payment to be eligible for any value-based payments. It may also be appropriate to request that value-based payments be completed before the contract termination.

Sequestration and other CMS payment reductions. Plans commonly try to pass the risk of a CMS-imposed payment reduction on to the physician. Physicians should delete any contract language that would allow this.

What can’t be negotiated?

Some language appears in nearly every MA value-based managed care contract and plans typically won’t modify the language. These include mandatory MA terms regarding record retention, CMS’ right to audit, termination for unsatisfactory performance and more. Also not up for negotiation are fraud, waste and abuse compliance obligations, as well as offshoring disclosures and attestations.