Hospital Contracts




© Springer International Publishing Switzerland 2016
Lewis A. Hassell, Michael L. Talbert and Jane Pine Wood (eds.)Pathology Practice Management10.1007/978-3-319-22954-6_11


11. Hospital Contracts



Jane Pine Wood 


(1)
McDonald Hopkins, LLC, 956 Main St., 02638 Dennis, MA, USA

 



 

Jane Pine Wood




Keywords
ContractingNegotiation (hospital contract)ValuationMarket rateComplianceExclusive providerCompensationBillingLiabilityIndemnificationAnti-kickback lawOffice of Inspector General (OIG)ExclusivityHold harmless clause



Case: A Sudden Threat

Community Pathology, P.C.’s contract with City Hospital is up for renewal. There is a new CEO at the hospital. The new CEO allegedly was recruited to improve City Hospital’s financial bottom line and cut expenditures, and the pathologists have heard that he refused to make Part A payments to the pathologists at his former hospital.

When Community Pathology, P.C. receives the renewal contract from City Hospital, there are several major changes from the existing contract. All Part A payments have been eliminated. The contract states that the group is prohibited from billing for its professional component of clinical pathology services. The contract charges the practice rent for its use of the laboratory offices for professional interpretations. In addition, the contract gives the hospital the right to bill globally for the hospital technical component services and the pathologists’ professional component services, with the hospital determining the amounts to be paid to the pathologists for such globally billed services.

When Community Pathology, P.C. expresses concerns to the new CEO, he responds that “If you don’t like it, then I’ll just put this contract out to bid to other pathology groups.”

What are the compliance issues raised under the new contract? Can Community Pathology, P.C. agree to accept zero Part A payments in exchange for the exclusive contract?

Does the hospital have any exposure under the fraud and abuse laws for the actions of the CEO? Do the members of the hospital’s board have any personal exposure?

What steps can Community Pathology, P.C. take, both before receiving the new contract and after receiving the new contract, to better position itself for negotiating with City Hospital?


Hospital Contract Negotiations for Pathologists


The negotiation of a pathology practice’s hospital contract generally is one of the practice’s most critical tasks . The dynamics of the relationship between a hospital and its hospital-based pathologists continue to change and become more complex. Payment amounts from hospitals are generally declining. In addition, third party payor reimbursement methodologies are changing, with more accountable care organizations , shared savings, bundled payments, and capitation . Both of these trends result in efforts by hospitals to exert more control over managed care contracting for pathology services.

Other trends include greater restrictions on outside activities by pathology practices as hospitals attempt to retain volume, shorter contract terms, and more contracts subject to competitive bidding.

Pathology practices must carefully plan the negotiation of their contracts with hospitals not only to maximize the Part A compensation from the hospital but also to avoid undue restrictions on their medical practices and outside activities. The parties must be mindful to avoid the compliance issues that would arise from a contract in which the hospital receives, directly or indirectly, inappropriate remuneration from the pathology practice.


Negotiation Preparation


The process of preparing for the negotiation should begin many months in advance of the expiration date of the current contract. A game plan should be established that would include at least the following preparatory steps:



1.

Review the terms of the current contract of the pathology practice with the hospital and determine if any problem areas exist from the pathology practice’s standpoint or from the hospital’s perspective. Have there been any tacit amendments to the contract that have not been memorialized in writing? Have any promises been made by the hospital of any future accommodations or contract modifications?

 

2.

Determine the strategic plan of the hospital. What is the hospital’s current and projected financial condition? Is the hospital in merger or affiliation talks with other health systems? How well is it doing in attracting managed care plans or the business of other third parties? Is the hospital planning any projects off site in which the pathology practice could be involved? Are any professional services which could be provided by the department being routinely sent to outside providers?

 

3.

Check with the other hospital-based groups in the hospital. What has been the general experience of the anesthesia, radiology, or emergency room groups in their negotiations? A word of caution is needed here. Agreements on the part of nonintegrated hospital-based groups related to what they will accept as fees, or prices, or collective activity that involves a boycott, refusal to deal, or the threat of either, can violate federal and state antitrust laws.

 

4.

Determine how the pathology practice is perceived by the hospital or the medical staff. If the perception is in any way negative, how can the pathologists act to change negative perceptions?

 

5.

Determine how dependent the pathology practice is on the level of hospital financial support it receives. To what extent (and how) could the pathology practice deal with various levels of change in that support?

 

6.

Determine what opportunities may exist in the next few years to provide services at locations other than the hospital, including other hospitals and freestanding medical facilities.

 

In short, groups need to “do their homework” before entering into contract negotiations with the hospital. Information and preparation is critical. Financial information and comparative data can be extremely valuable in negotiations or in responding to questions raised by the hospital personnel.



Preparation for contract negotiations is a critical part of the process, and best started before the ink is dry on the last contract.


Selling the Value of Pathology Services


As explained above, it is critical for pathology practices to educate their hospitals about the value of the services provided by the pathologists. As a first step, pathology practices should explain, in detail, the various types of pathology services that they provide, including anatomic pathology services, professional component of clinical pathology services, blood banking services, autopsy services, graduate medical education services, research services, outreach services, etc. The pathologists should ensure that the hospital administration understands the significant commitment of time and expertise required to provide these services, especially those services for which the pathology practice cannot bill payors or patients (i.e., services for which the sole source of compensation is the hospital).

If the pathology practice has one or more pathologists with specialty expertise, this pathology specialization and its relation to the provision of specialized services by the hospital and its medical staff should be emphasized. For example, one or more pathologists with hematology expertise offer significant support to the provision of oncology services at the hospital. A pathologist with pediatric specialization is vital to a hospital that prides itself upon its pediatric services. Without such pathology expertise, the hospital and members of its medical staff would not be able to provide the same level of specialized hospital and medical services.

The pathology practice should explain that quality pathology services are directly related to more satisfied medical staffs and patients, which means that the hospital is less likely to lose referring physicians and patients to competitors. Quality of care is increasingly an important issue to some payors, and the expertise of the pathology services can have an impact on the hospital’s ability to secure preferred managed care contracting.

Pathologists can effectively market the clinical laboratory and anatomic pathology services offered by hospitals to physician offices, surgery centers, nursing homes, and other health-care providers, and often are the single most important factor in a client’s selection of pathology and laboratory services. It is advisable for pathologists to assess the dollar value of the outreach services provided by the hospital, and explain to the hospital the critical role that the pathologists play in securing this business and retaining it.

Quality pathology services reduce the risk of malpractice liability for hospitals and attending physicians. If hospitals are interested in cutting costs and are looking for the “lowest cost” provider of pathology services, the hospitals may be increasing their exposure from a liability perspective. Pathology practices should remind budget-minded hospitals that courts have held hospitals legally responsible for the negligent selection of hospital-based physicians, and the more prudent approach for hospitals is to pay a reasonable amount to secure the services of competent and trained pathologists. In addition, pathologists also can assist hospitals in reducing their liability exposure through their supervision and oversight of hospital laboratory personnel.

Only gold members can continue reading. Log In or Register to continue

Stay updated, free articles. Join our Telegram channel

Oct 29, 2016 | Posted by in PATHOLOGY & LABORATORY MEDICINE | Comments Off on Hospital Contracts

Full access? Get Clinical Tree

Get Clinical Tree app for offline access