There we go, I'm a bit of a pacer, so we'll go wireless. So I'm Andrew, I'm the VP of Customer Success and one of the co-founders here at Rivet Health. So I work with all of our customers, about 250 customers in all different specialties, but we work with a lot of different orthopedic groups throughout the United States. So thank you, Shannon, one of our customers for that lovely introduction. Just as a reminder, if you have any housekeeping issues or agendas, and then there are the check-in codes, so that's 628015, as Shannon had mentioned. And then we'll review the checkout code and the APC code at the end of the session as well. So flipping through, today we're talking about contracts. You know, there's a pretty big divide between, hey, I've got all my contracts and fee schedules I wanna talk about, and then there's the, I wanna investigate APMs or alternative payment models or bundled and global payments. Today we're really focusing on the contract piece with your organization, your provider groups and building that payer relationships. So this is structured into three subcategories. So the first is assessing your payer landscape and how you identify which payers you wanna go after to tackle those negotiations. Then we'll talk briefly about building a model, a nice dynamic model, whether you have a contract management solution or you're a good old Excel champion, both those work just well. And then last but not least, talking about running a good process and how to stay on top of your, on top of your payers. So that, that's a, you can see, I am one in the same as that picture. So let's get going. So quick engagement, show of hands, who's ever negotiated a contract with an insurance carrier? Like 70%. All right, anyone have a good time doing it? Cool, yes, that, yeah, that seems to be the sentiment. So within assessing your payer landscape, to get going, before you actually go out and start reaching out to payers or anything like that, determine your team's internal readiness. So for the 70% or so of you who raised your hands and said, yeah, I've done contract negotiation in the past. Great, you have a leg up. And it's identifying who in the practice is gonna be the right or the key contact to handle point on that negotiation. It's not easy. It's not one email and this is effortless and done. It's consistent followup. It's, you know, speaking at a high level or an executive level to VP of network credentialing or provider enrollment or, you know, any of these departments at the payers. And then you always find, people who have done like insurance followup in the past seem to be really good at negotiations because they're kind of that bulldog and say like, well, I know you said no, but that's not good enough. I need better, you know, I wanna keep going. So not willing to take no, the initial no as the end all be all answer. So that's the internal readiness. And then who are your payer reps? So this continues to be this kind of trending, butting heads between providers and payers as payers tend to be like, hey, we've got a central, you know, psscentral.signa.com or use your generic Aetna inbox. And you wanna maintain those payer reps. We'll talk about it later on as we run through a good process. At the end of the day, somebody's signing off on that contract and that proposal. And so, you know, trying to identify who are you going to be working with during that negotiation? And then alignment throughout the organization of what do you actually want from this negotiation? Everyone generally just wants increased reimbursement or a minimum not to decrease their reimbursement, right? Sometimes payers will come out and say, we're changing your conversion factors or we're changing your Medicare baseline or we're changing the markup off of, excuse me, this particular market fee schedule. So you may wanna reduce the likelihood that you're actually losing revenue. So that tends to be the, one of the key objectives with negotiating. But you can also look at, are you expanding? Do you want to credential new services? Do you have a new ASC that you're looping in? Are the new procedures that have been recently authorized to be done in an outpatient or an ASC setting that you want to get added to your contract with those negotiated rates? So what are your actual goals and how do you determine if you're achieving those? What is a successful outcome? In many cases, for a lot of people, it's just a specific increase. Hey, I wanna get up 3%, 5%, 7%. Other people wanna talk about, these codes are currently bundled in and I wanna split these out or I wanna create a bundled payments approach. What do you actually want out of your negotiation? And then last but not least is you're determining your internal readiness is what do you really know about your practice? And we'll talk more about this as you go through the model and running a good process. But how do you differentiate yourself between a practice in another orthopedics group that's down the street, rather big or small? What do you, how do you kind of further segment your specialty, your providers, your, insert any of these variables that help differentiate you between the practice down the street? That's internal readiness. So evaluating payers. So first, I love contracts. I've spent a lot of time reading, I've read hundreds, if not, well, thousands of contracts, if not more, model a lot of fee schedules. And one red flag to look for is how old is your contract? So true story, I was working with a customer of ours a few weeks ago and their last model contract was in 2001. They were so old that their locality didn't even exist anymore. The CMS locality, their fee schedules were based off of, did not even exist. CMS had changed it back in 2011. And then again in 2016, and they were going off this thing that was 22 years old as a contract. And then, so just the language, everything, I mean, the references to state issues and clauses, super outdated. So how old is your contract? And then as a follow-on, do you even have your current contract? And that kind of relates to bullet six there is the amendments that follow on, right? It's not typical that you get a new contract every year. You may get amendments to that original contract that are either changes in terms, rates, clauses, language throughout that. But do you even have a current copy of your contract? Do you have current copies of your amendments? And then when are you able to take action? So we'll talk about this in a few slides, but there's a pretty critical window that negotiations have the highest likelihood of being successful. And that's while you're outside of what we call a change notification period. So the change notification period, got a screenshot of this, but it literally goes through and says, if you're not going to be renewing this contract on an evergreen or an auto-renewal clause, you have to notify the payer this many days in advance. Otherwise, it just goes in this auto-renewal. The reason that's pretty critical is you maintain that leverage if you're willing to walk from that contract. Now, there's always a big asterisk, like, well, I can't, they're my second biggest payer. I can't just do away with 15 or 18% of my revenue by walking from a contract, but it does maintain optionality if a payer really is striking out some of your reimbursement. And then just last kind of four or five there, using the baselines. So I mentioned the components of a fee schedule in this example that was referencing 2001 CMS rates is how old are the baseline components of the fee schedule that are governed or determined by that contract? In many cases, you'll see a payment appendix, whether that uses a market fee schedule like the Aetna market fee schedule, the Humana ChoiceCare 005-744, or in this case, CMS as a baseline, how old is that? And the reason that's important is CMS has a sustainable growth rate formula that basically budgets a certain amount of increase in reimbursement, and then they tend to adjust sliders. Some years, E&M codes go up, some years, surgical codes go up, but you tend to get different increases. So if your baseline is really old, chances are either the RVUs or the allowables that are being referenced from that old fee schedule are not kept up to date with inflation with cost of living adjustments. So how to look at how old the components of the fee schedules really are. So this inevitably comes up with every customer I work with and many, many practices, like, well, I don't even know who has these things, and I don't know where do we get those. So kind of what do you do if you don't have your contracts or fee schedules? Starting from the top, reach out to whatever payer rep you have, even if it's not a contracting rep. And that's where I say, when you get creative, I've had success when we initiate negotiations or try and obtain contracts that you could talk to provider enrollment or a credentialing department, and they're like, yeah, that's not us, but go talk to Billy. Here's Billy's email or fax number or email or phone number. So be creative, find contacts. You definitely have at least one contact that is going to be helpful. Could even be a follow-up rep. And they say, you could proceed through that and play the phone tree or the phone game of trying to hunt down who actually governs your contracts and who can you talk to. A lot of the payer websites, if you dig deep enough, will show you, at least from a region, who a good payer contact. And they might be the VP of network management over a specific region, but they can help point you to the right individual. Got to play the game a little bit. And different payers function different ways. So sometimes you can just go online and send a request. Other times you have to keep emailing, faxing. Like there's this one payer that we work with that requires a on your practices letterhead with tax ID and NPI and everything. It requires a written document to be mailed to them. But you got to play the game a little bit. And then something that we've always found, if you don't have a copy of your contract, and the first thing that you're going out for is, hey, I'm negotiating our contract. I want to know what we're getting paid right now. They tend to go radio silent on you. So there's a lot of alternative language that you can use to get around that. I'm negotiating, even though that may be your end goal. We want to gather all of our expected reimbursement. We want to understand what we are currently getting paid across all of our payers. And then I'm going to jump to three real quick, because there is some cross benefit to gathering your contracts and fee schedules. And this is something that you can use when you're talking to your payer reps to gather those payer documents. So one being, I want to help our patients understand what their costs are. But there are a few sessions around patient pricing transparency. And a component of that is, you have to know what your expected allowable is going to be or your contracted rates from the payer to be able to pass that on to the patient. So that is one alternative language that you could use for the payers. I need to understand what we're getting paid or what our contracted rates are so that we can push those to the patients and help them understand their out-of-pocket liability. Auditing payer reimbursement and modeling fee schedule changes. Obviously, those are two very big benefits of having your expected allowables. And then jumping back up to number two, leveraging existing websites and portals. Every time I say this, everyone's like, well, availability only lets me pull 10 codes at a time. I know, I know, kind of stinks, especially if you've got 800 codes that you're billing. But do this quarterly, once a year, invest some time. Vendors have scripts that can make availability really efficient for you. But it's going to be worthwhile getting those rates so you understand what you are getting, what your expected allowable is going to be across all those payers. Then this is a new data set that under the transparency and coverage, payers are required to post their online payer rates for everyone, all of their in-network and out-of-network historical allowables for payers. So this transparency and coverage produces these massive data files. We're talking just UnitedHealthcare alone, just their payer library is twice the size of Netflix's entire video library. It's the last thing I want to be doing on a Friday night instead of watching Netflix's reading payer rates. But these are huge data sets and you can pull it up by tax ID, by NPI. And so there's already companies that are beginning to harvest this data and make it commercially available. And so the nice thing is you can go and say, well, I don't need to reach out to my 10 or 20 or 15 different payers. I can go and pull, right now, I think the count's at something like 182 payers have all these rates available, all the big ones, right? Your Aetna's, your Cigna's, your United's, most of your state blues, Humana's, those all have these, all that data is available online. I think we pulled down, but it's really big. So you either need to like leverage your own data science team or work with one of the vendors that you can purchase this from. But, and we'll kind of put a pin in this until market benchmarks, it does allow you to pull comparative benchmarks in your market. So if you know that you're located in rest of Florida and you wanna pull other comparable orthopedic practices in your surrounding area, you can go and pull their NPIs down and there's nothing proprietary or secretive about NPIs. Anybody can find any NPI online, but you can go and pull that data down and use that as part of a negotiation. So it's data that's never ever been commercially available in mass like this before. So it's always been, yeah, you can like purchase it from a clearing house, but they aggregate it and there's lack of visibility between facility versus non-facility charges. This is literally your contracted rates. And if there's out of network rates, it also shows the historical allowables for those out of network rates. Now, one little asterisk to this is these are payer generated files. So there's not necessarily a guarantee that these payer generated files are going to match what's on your contract. And the reason we kind of read into that is this is why payment variances happen is somebody on the payer side is taking your contract with your payer appendix and they're loading it into their, basically their contract management suite. So if somebody mistypes a percentage or a baseline year or anything like that, the rates that you're expecting from your contract are going to be different than what the payer has loaded into these data points. So just a little asterisk on, you know, it's a good indication of what the payer thinks your rates are. It's not necessarily what your actual rates should be. And that's one of the big reasons that these variances or underpayments happen throughout the industry. And then kind of last slide here on determining your readiness and assessing your payer landscape is assessing your timelines. So hopefully you in the back can kind of see this, but this is an excerpt from a real contract that we had talked about that change notification period. And so right in here it says, either party gives the other party written notice of non-renewal of this agreement, not less than 180 days prior to the end of the then current term. So most contracts, once you initiate that contract, it's set with evergreen or auto-renewal clauses. Generally it's going to be for one year. And then this change notification or early termination clause basically says, this is how much lead time you need to give the payer if you want to opt out. So in this case, it's 180 days. You have to give the payer six months. Let's say it renews on December 31st. You have to notify the payer in June basically that you are not wanting to automatically renew this contract. And so that's some of the leverage that you can bring in that negotiation is, hey, I don't necessarily lock this in for my evergreen or auto-renewal. I want to make changes to this and you have that leverage within that window. So on to the preparing dynamic models. Out of curiosity, show of hands, who has a platform or software or something that they hold all their contracts in right now and model everything? Okay, that's a lot less than the people who have negotiated. So a lot of people just have used Excel in the past to model these. Yeah, head nods. Cool, so good attributes of a model. Definitely want it to be accurate, want it to be actionable and want it to be efficient. From an accuracy standpoint, using consistent data across all, excuse me, across all of your payers and then actionable instead of just posting out a bunch of raw data and forcing you to kind of read through the lines, identify where the laggards are, where payers that are good versus bad, what at a more granular level, what's good and what's bad and is it specific codes? Maybe your surgical codes are really good but your E&M codes are atrocious. And then efficient, you want to be able to model multiple drafts. And as you're going through the negotiation process with a payer, whether they send a proposal first or you send a proposal first, changes are you'll probably have to do a little bit of back and forth. You may come out and propose 5% or 7% increase and say, well, that's way out of budget for this year. We can do 3% or 2% or 1% or they don't even tell you the increase, they just send you back a fee schedule. So yeah, this is what we think for you guys. Load that in so you can have, this is what I initially requested, this is what they sent back, I want to counter with this. So that efficiency to be able to prepare multiple drafts. There's really two methods to benchmarking some of your data across your fee schedules. So the first one is we call it total utilization scorecard. And what this does is it takes your volume, every single CPT or HICPIC code and either a quarter or a year of volume and applies it to every single one of your fee schedules. And so let's say you do 50,000 procedures or 100,000 procedures, it takes all of that volume, says, yep, we're putting this on to Aetna, this to Cigna, this to United, this to Medicare, and 100% of your volume goes onto every single fee schedule. This is really nice because it allows you to benchmark without having to go through the nuance of, well, this payer gets assigned to this fee schedule, this payer gets assigned to this fee schedule. So you allow for simple benchmarking on your best or worst payers. And it's a very good mechanism to show as a percentage of a common kind of underlying reimbursement term. So a lot of people will say, at a minimum, I wanna know as a percentage of Medicare, benchmark all of my payers to Medicare so I can see of my commercial payers, here's my good and my bad ones. On my Medicare Advantage payers, here's my good and my bad ones and what the percentage of CMS is. Some of the cons, it doesn't actually account for different payer inclusions. So real example, we've got a group that Blue Cross, when they're in physical therapy, doesn't pay for ice packs. So they have this like 99.8% denial rate for ice packs because it's just bundled. But for whatever reason, Cigna does. It doesn't account for those payer nuances that some things are covered or not covered or bundled or unbundled. And then if you happen to have any differences in procedure mix per payer, so you might have more, for your elderly population that's on Medicare, you might get more total joints for some of your commercial payers, you might get a different procedure mix. So it doesn't account for any of those payer by payer specifics. What the inputs and the outputs generally look like. So on the left side, you have an example of utilization. So that left column you have, where is this being done? We call it a rate type. So in the orthopedic world, at least on the physician side of the orthopedic world, not necessarily the ASC, you have two rate types. You have what we call a professional non-facility. So that service is done in place of service 11 in your clinic. And then you have professional facility, which are gonna be the surgical or professional component of something done in an ASC, done in an outpatient hospital, inpatient hospital. And those have different rates, as you'd expect. Generally, the key difference between non-facility and facility are going to be that your facility rates don't have a PE component or a practice expense or the overhead because you're doing it in someone else's facility, in an ASC or a hospital. So that's utilization. You've got where is it being done, your CPT codes, any hard-coded modifiers. Generally, most of the hard-coded modifiers are 26 and TC for those imaging procedures. And then you have your annualized volume on that fourth column there. On the right-hand side is a rate table. So this is what, you know, something that you should be able to populate. It has your CPT or HCPCS codes. Then it has the names of your fee schedules at the product level. And that's going to have, for these different rates, or these different CPT codes, here's the rate for Medicare, for Cigna, for the MedAdvantage, for the EPO, PPO, for Mediband United, for the UHC All-Payer. And it just goes through a list of, here's all of our fee schedules for our billed codes so that we can basically put all this data into a big equation that spits out, if I put all of my utilization onto each one of those fee schedules, that bottom is going to show you what is your projected net revenue or your cash for that. And so the greens and the reds just compare, are you higher or lower than what the benchmark is? So in this case, the benchmark is your rest of Florida Medicare. It says, yeah, you're going to be $18.5 million if you put all this volume onto your Medicare fee schedule. If you put it onto your Cigna Medicare Advantage, you're at 15 million, dramatically less. You've got Cigna, which is a little bit higher, and then all the way on the side, you've got United All-Payer that is 22 million, dramatically higher than your Medicare benchmark. And then you show what that percentage of the baseline is. So going back to that previous slide where it allows you to show a general percentage of some baseline, that's what that very bottom line is. It says, yeah, as a rule of thumb, this is what your payers weighted to your own procedure mix. This is what your payers will be paying you. The second type of model, it's what we call a payer-weighted utilization model. And the difference between this is you take it one step further. You have the same utilization, but you add in a payer or an insurance product name. And then you take that product and you assign it to a specific fee schedule. So you take the Aetna as you assign it to the Aetna fee schedule. You take the Medicare volume, apply it to a Medicare fee schedule. The pros is you get better payer mix modeling. You know what your biggest payers are, what your smallest payers. And if you have a really bad payer that makes up a fraction of a percent of your volume, probably not worth a ton of your time going after that payer. And then you do, you have some really fun improved net revenue forecasting. So now that you've taken it down to the level of, hey, these are all the insurance products that I bill out. Here's the corresponding fee schedules for those. You have much better net collection rate forecasting and net revenue forecasting. Some of the cons does take a little bit longer because you have to read through. Most PM systems or EHRs have somewhere between 100 and 500 different insurance packages that your team has just built up or accumulated over time. So you take those and you have to tie them to fee schedules. So it does take a little bit longer, but you get a lot more accurate data. And the key difference being you now have a third line in that exact same model. And that is the percent of the payer mix. So the one we have highlighted is our Cigna Healthcare Medicare Advantage. It says, well, yeah, that's 82% of our benchmark of Medicare and it makes up 14% of our payer mix. Like that is a pretty substantial payer in terms of in what revenue could be. So it just adds an additional component of how meaningful is this payer for you. And then the kind of last few components here of the model piece, I love quick edits, mostly because I like drafts and I like playing around with what-if scenarios. So you may be able to build out, whether it's 2% or 5% increments and say, yeah, what if I got a 3% increase, a 5% increase, a 7% increase, a 10%? Giving yourself the ability, if you're doing this just in Excel, to kind of quick access these with either scenario modeling or what-if modeling in Excel, where you can click a button and say, I wanna drive from this baseline to this baseline, or I wanna drive from this markup, you know, 130% to 135% or 140%. These quick edits let you dynamically adjust your rates. Say, well, yeah, this is what I'm going after. This is a low end, this is a high end, but this is where I'm targeting for this negotiation. The custom scenarios is really easy. It is a feature for everyone, except for the three people that raise their hands with contract management products. You know, it is a what-if scenario analysis in Excel, and you can build that out and you say, well, I want it to go and change these specific values. And one of the most common ways to do that is through category markups. So a lot of payer contracts, if you can picture a UHC payer appendix or anything that says your surgical codes get paid this, your E&M codes get paid this, a medicine codes this, everything has a category markup. And so you can play around with those once you put in your different fee schedules and your volume and utilization, you can plug and say, well, yeah, I wanna start with my surgical codes at 140% of CMS, and then I wanna play around at 145, 150. And you can do that for all of your different categories. Cool. And then the last benefit of a model is dropping in your charge prices. And so why do you charge prices? First of all, they rarely actually matter. And this is kind of a funny hot topic that in many, many cases, what your gross revenue is as a practice is almost worthless. It's not what you get paid unless you have some crazy legacy contract that's percent of charges, way more likely to happen in an ASC or a hospital. But on the pro fee side of things, most of your components are either gonna be CPT or HCPCO driven fee for service, or you're in some type of bundled payment structure. But they don't matter until all of a sudden the lesser of clause hits. And the lesser of clause is defined, this is an extract from a real contract. The company will pay the lesser of the contracted rate or the eligible bill charges. So if you're billing out at 27447 and your contracted rate for that is 2,500 bucks, but your charge price is $2,000, the payer can completely legally in good conscience and faith pay you $2,000 and you're leaving $500 on the table every time you bill that procedure. So this is really just like a quick check. And a lot of groups structure their prices in such that you're choosing 200% or 250% of Medicare and saying, yep, we don't have any contracts that pays 200% of Medicare, so we're good there. You'd be surprised that there are times that payers fluctuate in a specific service line or type of code is randomly paid at 300%. And every time you bill that code, you're literally leaving money on the table. So some of the red flags, that bold with the big three red flags there is if you do have claims that are paid at 100% of charge, meaning there's no CO45, hopefully to an extent you're familiar with what CO45 is, it's just that contractual adjustment that takes you from the gross charge price down to your net allowable, your contracted rate. If you have no CO45 on that and it's through an insurance, MedAdvantage or commercial insured payer, that's a red flag that your charge price is not high enough. You can go through, look at what the rate should be, adjust your charge price and capture that additional revenue. So it is a quick win as you're going through and you've taken the time to build out and model your contracts and fee schedules is dropping your charge master. Hopefully you're structuring towards a consolidated charge master instead of a bunch of different ones that you have just one consistent charge price. You wanna make sure that you're capturing your net revenue and maximizing that without necessarily impacting your gross revenue too bad. Yep. Sweet. So the last 10 minutes or so here we'll talk about running a good process. So it's a who, what and the when in negotiations. So internal and external, who's the right contact at your payer and or at the payer that you're targeting and at your practice to run this negotiation? What are you actually seeking? What can you actually change? Sometimes people will be like, yeah, I wanna change this, this and this. And it's like, well, that's a global payer term. It's published on their website as a uniform global term or clause in their contracts. You don't have the leverage to change that. And then when, we've talked about this a few times, but when will this actually be effective and how long will negotiations generally take? So in that order, who you work with matters. Do your best to keep pushing until you get a contact, a name of anybody, an email address, at least a department head or department owner. And the reason that I know these exist, A, I've negotiated a lot of contracts, but also at the end of day, somebody has to approve this negotiation. It's not by consensus, by board approval that says, yeah, these 12 people approved your negotiated reimbursement. It's someone very specifically is signing off on your contract, right? If you've seen those contracts, like page 37 is a signature line and it's somebody from the practice and somebody from the payer. So at the end of the day, somebody is approving the negotiation, drive towards somebody who's a decision maker at the payer. And then also make sure that the person internally has the authority to negotiate and make approvals. So another true story or their group, and they, this person was a dynamite negotiator. And then, but they had kind of given up ground that they weren't authorized to give up on. And they had to backpedal with the payer and say, well, actually we can't do that in this year. And this is the reason why. It just kind of was a little awkward. So make sure the person from the internally, that they have the authority to negotiate and make those extensions or approvals. And then on the other end of the payer side, do they know anything about your practice? Do they know anything about your market? If you're looking at, right, these generally these VP of network developments, they've got big regions, right? They might have an entire state. They might have a whole locality of thousands of different groups, not just orthopedics, but they've got all these different specialties and multi specialties. So what does that individual know about your practice that makes them a compelling group to negotiate with? So who you work with matters, and what do you actually want? So many of you have probably heard this phrase called a BATNA, the best alternative to a negotiated agreement, which is basically your bottoms out point. So always recommend going in with a target of what do you want out of this negotiation, and then set an upper and a lower bound. That upper bound could be maybe you wanna get 5% from this specific payer. And that upper bound is anything over 7%, amazing. We are crushing it, I'm the best negotiator in the world. Anything lower than 2%, and all of a sudden, you're falling behind on certain things like cost of living adjustments, what you're paying new providers entering your market, maybe you have to compensate certain providers to recruit them to your practice. So what are your upper and lower bounds? And your BATNA is like, when are you willing to actually throw in the towel on this thing? And then what terms in the contract are negotiable? So there, as you're reading through this 35-page insurance contract, there's a bunch of terms, right? Some of these are insurance and indemnification clauses. Some of these are when do you have to make changes? How long does this contract go for? Is it evergreen? Is it a multi-year? Are there cost of living adjustments? Some of the things that you should look forward to is that multi-year agreement. So if you can bake in a three-year agreement with a few percentage increase points every year, that evergreen on the cost of living is gonna be beneficial. A, you're gonna save yourself a lot of time having to go back and negotiate this every year. And then B, you're gonna realize that value, and it gives you a little bit more flexibility when you're working with payers that if you wanna get to 7%, you might not get to 7% increase right away, you might be able to structure it in a couple percentage points every year. So what terms are or are not negotiable? Certain things like timely filing and clean claim payment windows. A lot of the clean claim payment windows are set by state mandates, your Department of Insurance, and says, yeah, if there's nothing wrong with this claim, we'll pay it in 45 days. Generally, you don't have a lot of flexibility to negotiate those, but certain things like change notification period and say, yeah, I wanna be able to terminate this with a 60-day notification. You can kind of address those with the payers. So we had talked about that third bullet there, the comparable market benchmarks. So really, there was no way to get this data. And even in many of your contracts, it was explicitly stated that you cannot share, you cannot collude with rates and say, here I am in Orlando and I want this ortho group and this ortho group and this ortho group, but we all wanna share our rates so we can negotiate as an entity, right? Unless you're a CIN or a clinically integrated network, kind of an IPA or PHO, you could not do that. But now this market data allows you to benchmark across geozips or population areas. You can say, yeah, these are five other ortho groups and how do I rack and stack relative to those payers? And then kind of the last outcome is a lot of groups that I've seen recently want to add consistency to their rates. So contracts are all over the place using different baseline years. Some of them update every year when CMS publishes a new fee schedule. Some of them are fixed with a bunch of different baseline years and it's just a nightmare to manage all that unless you have a product for that. And so you may want to move all of your contracts and fee schedules to a consistent structure. And maybe that's, yeah, I want a dynamic percent of Medicare and I want them to kind of tighten in onto X percentage above CMS every year. So that's what you actually want. And then just when you'll realize the fruits. So if negotiations are on your roadmap for this year, keep in mind from the day you start, it'll probably be three to six months until you start getting paid those new rates. And that's on a good case. And that's assuming you hit it at a good time. A couple months just for the negotiation back and forth, payers aren't incentivized to do this quickly at all. So it's on you to keep following up with the insurance company. And then even when you think you have a deal, it's gonna take their team generally one to two months to actually implement that, build your new contract adjudicating claims at the new rate. Something to be aware of with that timeline is get an effective date. It could be articulated on the signature page that this contract is effective the day that it's mutually signed by both parties. Otherwise, it's a kind of a clause on that contract to say this is the date that you should be expecting new reimbursement. Have a system in place to start expecting that higher reimbursement. So if your previous rate was 100 bucks, you're now expecting 105 bucks on what, June 1st. The day June 1st comes on for any dates of service on or after that, make sure you're getting paid your new rates. That is, otherwise you're gonna be leaving that money that you worked so hard to negotiate back on the table. So some common objections with just a couple minutes left here. One being payer states that rate changes are off the table this year. They always say that. It's like, it happens all the time. Start to communicate when was the last change in your contract? When was your last rate increase or decrease for that? How was cost of living adjustments? How has that changed over the last period since you've negotiated or had a rate change in your reimbursement and articulate your value to the payer there? Second objection, your rates already appear market competitive. That may or may not be true. Now we have market benchmarks that you can actually pull that data down and say, well, according to these five other close proximity orthopedic groups, I'm actually in the lowest quartile or, you know, it also might be really informative if you happen to be extremely high that maybe you don't poke that there. Outside of the key negotiation window, you know, if they really do say you can't make changes until this period, the best you can do is start to prepare for that negotiation. So you have plenty of lead time to do your data modeling, your outreach, find the right contact. So you've got that lead time, you get on top of it so that you can begin to address those as soon as that window opens up. And in some cases, we've seen negotiations be successful prior. You just have, you know, five, six months until that new reimbursement becomes effective, but you've already got things locked down with an effective date. Something to think about is, are you willing to walk? It's a hard question, especially if it's one of your top three payers. But if it's maybe not necessarily critical to your revenue and that you could replace patient volume or schedule volume with a different payer, like keep that in the back of your mind. It's, you can always walk and rejoin a network, especially if you're a key differentiation as a provider, they want you in that network, right? Payers want good providers. Yeah, so some things that you can think about, whether, you know, if walking out of a network is on the table and just articulating your value to a payer network is what really differentiates you. Are you a high cost or high quality, low cost provider? Do you have certain objective metrics that you can articulate back to the payer? Your MIPS scores, are you enrolled in APMs or alternative payment models that are cost or risk-based? And you have a score that gets presented to your group and says, well, yeah, this is where you rank on the quality of provider. Same thing, a lot of your ACOs, if anyone participates in those accountable care organizations will provide kind of metrics, performance metrics to say, well, yeah, this is how you, this is where you rack and stack on the banding. And I tend to believe that a good quality provider with slightly higher rates is a much better network participant and actually a more cost-effective network participant than a low quality provider with lower rates. And there's a lot of sources that you can also, I mean, whether you go to Google or Healthgrades or most of the payers have their own metric system on like, yeah, you're a two heart provider from UnitedHealthcare, whatever that actually means, it helps if you can bring that to UnitedHealthcare. And then last but certainly not least is be confident you got this. You've had plenty of time to prep, you have your data, you know your position in the market, you know your position in the rates, what are your benchmarks? Don't take the first no as the end all be all or the answer. Payers are often going to give you that initial no. Same way that like payers oftentimes deny claims and all you have to do is fight it and say, no, this is why it's medically necessary. Show your justification and your reasoning and then know when and where you want to draw the line with the payer. At the end of the day, it's either a go, no go. Do you want to stay in the network with the payer or do you want to like bring it up to the providers or the exec board and say, hey, this payers is not a good one for us. They, maybe they have high denial rates. They pay exceptionally low on some of your charges that you might even be underwater on some of these procedures just based on your provider comp models. So know where and when you want to draw the line. And the thing that I also will remind or kind of hit home is don't check in with your payers once every three years. Use this, once you identify that contact, right? And you fight to be like, who do I need to work with? Use this as an opportunity to build long-term rapport with your payers. So whether that's just a quarterly update on new initiatives or like, hey, we just built a new ASC, like fun things are coming down. Use it as an opportunity. That way, the next time that you check in with your payers, it's not gonna be three years out and it's you banging on the table for a rate increase. So with that, we'll go ahead and call it. We're right about on time. I'd love to chat with you all about questions that you have around contracts, managing contracts, negotiating contracts. That's my email. Feel free to write it down. Ping me if you have any questions. Thank you.

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