Most physicians consider "managed-care contract negotiation" an oxymoron. In most cases it's seemingly impossible to go back to payers after the ink is dry and secure better rates. Nonetheless, some physicians are pushing back on the insurance companies — and winning.

Associated Cardiovascular Consultants in Cherry Hill, N.J., did just that and succeeded, thanks to good clinical data.

"Without data, it's hard to negotiate," says Steven Fox, MD, one of 31 physicians in the group. "What [the payers] want to do is save money. You need to be able to prove that you're a quality practice, that you are not over-ordering and readmitting patients ... . If you're going to control your future, you need to do your own homework."

Fox and his colleagues are living proof that when practices can demonstrate their clinical excellence and their value to the payer, or show the payer that its fees are too low, they can win at the negotiating table.

"Doctors tend to think they can't do anything about [poor payments], but they can. Just don't go at it from a hostile point of view ... . Get in there, build a relationship with these people, sit down next to them at a table and talk about it. Say, 'What would you like from me, and here's what I want from you,'" says practice management consultant Judy Capko of Capko & Co. in Thousand Oaks, Calif.

John Morris, executive director for Associated Cardiovascular, remembers the day three representatives from one of his major payers visited, concerned about the practice's patients with congestive heart failure. Evidence-based guidelines say these patients should be prescribed a beta-blocker and ACE inhibitor. The insurance company —  relying on information from diagnosis and CPT codes on 59 patients — contended that the practice appeared to write those prescriptions only 74 percent of the time.

"I let them finish," Morris says, "and then asked, 'Would you like to see a study based on 3,000 patients?' They said, 'Oh, sure.' So I showed them, and they were just wowed."

Using its EMR, the practice was able to prove that it was, in fact, compliant with the beta-blocker and ACE inhibitor guidelines 94 percent of the time, and that if a patient was not on the recommended drug therapy, there were clinical explanations for the aberration 20 percent of the time.

Dialogue gets dollars

"Their data and our data were like night and day. It's amazing. Most of the time the [payer] data is just wrong," Fox says, adding that it's imperative that physicians take charge of the negotiation process.

"They were excited about [the data], and a bunch of things followed," Morris adds. "They invited one of our doctors to be on their advisory board. They've given us a little bit more money for all of our codes."

The group decided to take the same data to other payers. "If one payer will [pay more], so will others," Morris points out. "In one instance, we got a 22 percent increase, in another one 10 percent, and in a third about 15 percent."

None of these payers had established pay-for-performance programs, but "we were the ones to bring it up," Morris says. "What that means is that we've opened the dialogue ... .  Every other week either I — or one of our physicians —  will get a call from one of these insurance companies with a cardiology question ... . It's great that we now have an open dialogue with our three biggest payers. We can talk about these things in a business-like way instead of pointing fingers saying, 'You're ordering too much' or 'You're paying too little.' You can't put a price on that."

This practice's EMR was essential to proving performance to the insurers. Fox was initially skeptical about the practice's Amicore software, worried about the price. Now he is a believer: "If [the EMR] can help us cut deals and take better care of patients, it's worth it."

"We went into the EMR because we thought we'd save money. Now we look for ways to make money with it," Morris adds. "Insurance companies are willing to listen to you when you have data."