Talk, Terms, Tactics: How to Win Payor Contracts in Behavioral Health | Expanding Access Podcast
Hello everyone. I’m Solom Tibu. I’m the host of the Expanding Access podcast where we’re covering all things expanding access to mental health, addiction, ID services through technology, health equity, and innovation and covering stories of lived experience and industry professionals. So, of course, I’m so excited to have longtime friend and BHT OG David Recupo. Thank you so much for joining us. So excited to jump right in. Why don’t we get started with tell us a little bit about your background, what you do, and how did you get into this space? Sure. Thank uh one, thanks for having me. Be tech has been great to see grow. I’ll say uh you know I remember you know 5 years ago I think it was the text message in the middle night of hey do you want to start a conference and here I’m getting interviewed at it and I think this will be what is this the fifth year we’re now in in coming November sixth total third in person third in person that’s right and I haven’t missed one for the record but um uh okay yeah thanks uh my name is David recoup I’ve spent the past eight years in the behavioral health space so primarily focused on business development for the past three and a half years right now. I work with or work for a Therapeutic. So, we’re actually a CARF accredited virtual provider for substance use disorder treatment. So, we focus on Medicaid populations. About 90% of our members are Medicaid. Uh though we do serve some commercial and and and Medicare members as well. So, but uh you know to kind of give you a brief overview of what FX does is we treat opiate use disorder, alcohol use source, stimulant cannabis um kind of like our secret sauce is we use contingency management. So that means we provide financial incentives for engaging in recovery focused behavior. So if a member attends a counseling appointment, if they get a negative drug screen, right, they get a financial reward for that. Then and the reason why we do that is uh contingency management is actually the gold standard for treating stimulant use disorder. That’s really how we got our start and since then we’ve expanded into other condition including programs uh that incorporate uh medication assisted treatment. So really what it looks like for a member to go through our program there’s a there’s an intake uh there’s monthly medical visits with a physician. So medication management, co-occurring disorder management. uh they do weekly counseling sessions, twice a weekly group counseling and ongoing support from our member advocate team. So that’s like a peer support. I call it the the Door Dash for recovery, right? Anybody can reach out to these folks and they’ll help uh you know link them to services and and I close out here because a lot of folks always ask me, well then how do they get the financial incentives, right? So they’re actually distributed through the affect mobile app and it’s uh they’re sent to each member also gets a smart debit card. So that that member sees the uh hey book I attended this appointment or have this negative drug screen. The money the financial reward there instantaneously hits the app that gets linked to the smart debit card and these pe and then these uh individuals are out there uh you know where they live you know spending this on food, gas, whatever it may be. So that that’s effect. Um and then I guess I’ll close out here with I’m also the co-instructor for the out-ofpocket how to contract with payers course. So, um, this is, uh, it’s an online course. It’s through out ofpocket.alth. And it really just, you know, my goal was to to demystify the payer contracting experience because when I entered in here, I had no idea what’s going on. I still feel like I have no idea. U, but the main goal was to uh kind of I don’t see payer contracting as being too complex. I just see it as it being like kind of hidden. I don’t know what to do. So the main goal is toify that and uh give you the essentials to contracting with payers whether it’s things about strategy, how to pres how to present, how to negotiate, deal closure and and so and then by the end of it you know you have like a playbook if you will um how to navigate future contracting uh you know endeavors. Really great. and you’ve not only been a business development leader for a variety of behavioral health companies, but just uh such a great advocate for the topic and advisor to so many including us. And so really great to see that you actually put together the course. It’s a wonderful resource. We’ll include the link for everybody. But let’s hear a little bit about the secret sauce that you share. Uh why don’t we get started with let’s say I am a behavioral health provider. How do I get started with contracting with a payer? Sure. I mean, the contracting process, right, with payers typically starts the same way for everyone. You visit the payer’s website, you fill out a form, you download a PDF and fill out that form. You submit it in uh you know, to request a contract. Um some during this process some plans will ask for supporting documents like your certificate of insurance, your state license, your Medicaid ID, a provider roster and then once submitted uh usually have to wait 30 to 60 days to hear back whether or not they want to move forward with you. Um if they do great you know you then submit typically credentiing materials and from there it takes another 30 let’s say to 90 days to receive um an actual contract and effective date. Now, now that’s the standard path, right, that kind of everyone goes through. Most providers aren’t looking for a standard contract, right? They want better rates um than the traditional fee schedule. And you know, that’s enhanced rates, pay pay for performance incentives, bundle payment, shared savings. Um and that contracting process is different. And this requires more conversations with folks at the plan, right? This isn’t just an application you fill out and boom, you got a valuebased contract. Uh but these are conversations you have and that could be anyone. uh that works in contractor, network, clinical or seauite. Um you you really have to hustle to find these folks. Uh so so that those are really the two most common contracting options, right? Option one, you apply on site on the site and get a uh fee for service contract. Option two, you need to find someone at the plan to negotiate uh uh a valuebased contract. So, fair to say that the valuebased contracts, which we’ll get into a little more, require a little more partnership and trust building. Before we’re going to dive right into that, I guess would you say a fee for service contract is is kind of a given. You just apply and you’re in then for those for the most part. Um, you know, some payers have closed networks because, let’s say, they feel they have enough providers. Uh but for the most part there’s so much demand for behavioral health services. Your payers are always willing to accept new providers. Um I’ve been in the position where sometimes you know a payer does deny you uh deny your application because let’s say they have a closed network or they they feel like they have enough providers. Um I wouldn’t ever just you know I wouldn’t recommend just to accept that. You know try to find out why the why behind why you know they don’t want to accept you. Maybe they have maybe it’s enough capacity, right? Dig in and try to find out, you know, maybe they’re lacking providers um in other areas. So, uh you know, go on their website, dig around. Maybe they lack access in rural areas or treating pregnant members. Um offer to just treat uh offer to target and just kind of treat those members for a set period of time. And after that, you can evaluate outcomes or your progress. But the main goal is just try to get in and once you’re in and you do good work, uh you’re good for the most part. And for the newbies listening in, what’s a closed network? Yeah. So, a closed network is essentially a payer feels like they have sufficient network adequacy to where they don’t need to add any more providers. So, a use case would be like this. Like I’m a payer in Arizona. Let’s say I have my member population. I’ll give you an example because math is hard. I have 100 members and typically only one provider can treat one member, right? So I basically need 100 providers then to treat my 100 members. And once they have that, that kind of looks like, oh, they have network adequacy, right? I have enough providers to treat um all my patient or all my members. Um and and so when they do have that, they kind of want to stay there because additional complexity such as, okay, if I have to add new providers to the market, I have to do more credentiing. I have to do more licensing. Maybe just take more ad admin work. Also, if I’m just adding in providers whenever I want, maybe I might not be able to control quality as well. So, um I understand the value uh to a a closed network for health plans because it just really helps them control quality more and uh kind of like less less administrative work. But, um I would say, you know, in my experience, maybe 5 to 10% of the time you run into that. But there’s always reasons you can uh uh present of of why they should let you in and the value you provide. Super helpful. So, of course, you know, behavioral health tech, we talk a lot about making that transition into valuebased contracts, and I’d like to ask you how one would do that, but maybe you could define a little what are the different characteristics of a valuebased contract that a provider should expect. Yeah. Yeah. Absolutely. Think think of um I like to think of value based think of value based contracts on like a spectrum, right? The left to the right. you know, I’ll explain the contracts, but from the left to the right is also um how much risk you’re taking and also contract complexity. So, on the very far left, right, you have fee for service, right? You’re not really taking risk, not a not a complex contract, right? Um you know, you you send in a code, you get paid. And on the very far right of it, um is capitation, right? You’re basically assuming the risk of a population that the health plan has. um there’s a lot of risk there and there’s also a lot of complexity. So think of it think of it like that. So to fill it in on the far left you got fee for service and then the next step up from there is pay for performance. So where hey if you lower something x% you get a dollar whatever it may be or pay for reporting right every time you report that you made a referral into this you you you get a dollar. Um and then the next step from there is like a bundle or case rate. They’re they’re used interchangeably interchangeably, but this is essentially hey a payer is going to pay you a lump sum every month for a group of services. So let’s say you have an eating disorder program and in that program generally you do four therapy sessions a year or excuse me four therapy sessions a month um one medical appointment whatever it may be. You basically take all those encounters and the cost associated with those encounters, you wrap them up and and that’s that case rate or bundle rate. And then the next step is the shared savings. And shared savings um really is defined, think of it as saying, hey, look, I think I can share or I think I can save money uh by providing good outcomes for your population. Whether that’s, hey, I can reduce ED co emergency department costs or inpatient costs. And because of that, you know, I want to be rewarded for it. So, a health plan will say, “Okay, great. Let’s say the average emergency department cost of each one of my members per year is $10,000.” Uh, if you, for example, um, as a provider treat that member and the average emergency department uh, cost for that year is 9,000. So, it went from 10,000 to 9,000. There’s a $1,000 margin in there, right? you’re basically saying, “Hey, I want to um participate in that $1,000 savings that I provided. Why don’t you give me 50% of those?” So 50% of that $1,000 is $500. So that’s shared savings. And then you can also build risk into that. So hey, if uh we if we save you money, we we um uh we get paid a bonus for that. But if we if our cost that emergency that emergency department cost I just explained, you know, it came in at 9,000. So, we’re saving the plan money, but if we came in at $11,000, we’ve actually cost the plan another $1,000. So, that would be called downside risk. So, you would actually be on the hook on that. And then, like I said in the beginning or uh the far right of this is capitation, which is, you know, full risk. You’re managing a population. And um it doesn’t necessarily have to only go from left to right. You can mix those. Uh you know, you might have a bundle rate with pay for performance measures or a shared savings with pay for performance measures. But, um, that’s kind of like the the the the contract buffet you you you can pull from. Um, and and you can kind of choose from and but it always depends kind of on what’s the payers what are the payers most comfortable with. Okay. So, needless to say, we don’t want to be flippant jumping into valuebased contracts, but now let’s say I’ve had quite a few fee for service contracts under my belt as a provider. What do I need to do to make that transition into my first valuebased care contract? Yeah, great question. Ask that uh question every day to myself. Um I mean from the from the very basics, you know, to help everyone out. Number one is, you know, getting someone at the payer to discuss uh the option with you, right, which is which is a challenge, right? So, um that’s that’s tough because you’re starting from square one, right? Who do you email? how how long would the process take? Uh really the most effective process I recommend as far as kind of breaking into a payer and having these conversations is actually doing two things in parallel. Apply to join their network through the traditional way, right? The website like I explained um and hustle to find folks you think can assist at the health plan with with the value contracting. So email, call, do whatever you need to do to get them on a call. Um and I I kind of call this parallel process. I actually call this in the course um applications versus conversations, right? You’re basically doing both. Um and the value of doing the traditional route, even though you’re shooting for a valuebased contract, um is while you’re searching for folks to actually have these conversations, you’re on LinkedIn, whatever it may be, um the traditional route will actually help uh make the conversations part easier. So, for example, um if you’re starting from square one, you need to hustle, right? To find someone to talk to. Uh when you apply through the traditional route, you’re going to be introduced to a provider rep or a contract negotiator. You can really lean on these people for contacts at the company. Uh you need to reach out to and discuss the value based uh uh contracts with um in fact, they might be the right person you need to talk to first anyway. So I’ve seen payers do vab contracts at the seauite level and other folks that have done them just you know um at the the contractor level right or the first person you’re introduced to. Um and you know a case for that is a lot of payers now might have these boilerplate uh already built valuebased contracts for your provider type that you can op opt into. You don’t know. So that’s why I say start on both angles. Um, the other benefit of applying the traditional way is it helps with your messaging and your conversation. So, when you send an email, right, to someone that, hey, can I’d like to discuss value based contracting with you. Um, you know, saying you’re a provider that isn’t even contracted is hard for them to prioritize, right, with all the work they have to do. Um, but by saying that, hey, look, you you’ve applied, you’re going through the process, you’re getting ready to get contracted, you know, it shows that you have skin in the game and you’re more likely more likely to entertain a call or respond to your email. Um, and the last thing is is let’s say you only spend your time time trying to have a conversations, right, with someone. You don’t want to go the traditional route. You’re special. You want to talk to someone at the health plan about a valuebased contracting. Well, when you finally get on the phone and let’s say they do say yes, um they want to do a web based contract with you, you know, guess what you now have to do? You have to go through the traditional application process because you still need to apply, present your license, your insurance, um you know, and everything. And uh the last thing is let’s say you only spend your time trying to have conversations with someone at the plan, right? you’re special. You know, you really want to just have that highle conversation. When you finally do get on the phone and they say yes and they want to do a value based contract with you, well, guess what? Uh, you still have to go through the traditional application process. You’re still going to have to submit your licensing information, your certificate of insurance. Um, so even if you get all the way through a fee for service contracting process and they send you a contract as well, you don’t have to you don’t have to sign it. Don’t feel like you’re you’re going to be going through this traditional fee for service process that you’re going to be stuck that way, right? You can always kind of sit on that contract until you’re ready. So, you know, the the key takeaway here is I say don’t wait. Submit the application uh the through the traditional way and also start the conversations at the same time. And doing both is really how you can move the process forward and give you the the I would say the mo most likely way to to get connected and get things going. Great. Okay. So, let’s say I am on top of my application, got that submitted, but like really want to break it down now. Let’s say I secure the phone call with the right person to have that initial conversation for the valuebased contract. Like what am I saying exactly? Sure. Um well, first, you know, um don’t overthink it. just you know introduce yourself and then really from there it’s hey asking the payer what their priorities are right whether it’s this year the next 3 months you know are there any quality measures uh they’re trying to improve are they trying to reduce pharmacy costs ED utilization really find this out but also find what the top ones are right they’re going to give you a list um dig in to try to find out what are the top one or two also if you’re selling to Medicaid plans you know you can look at things like the state website and see what quality measures the state has prioritized Um some states even have scorecards that show you where where the health plans rank. You can find um sanctions. So hey look, there’s um if a health plan ranks below a certain quality measure, right? They can get fined. Um also you can look at quality withhold. So um some states will let’s say hold 2% of the total PM uh the total capitation amount that they’re giving to these MCOs. um and they have to earn it back through quality measures. So really kind of find out where the money is. Um and then also so so that’s kind of like the outline of what’s important to them. And the other thing is really qualifying, right? Ask if they’ve ever done any valuebased programs for your provider type in the past, right? Are there are there any currently build? Um some some payers have programs you can join, right? That’s the easiest way. you know, ask if they currently do any form of value based contract. Um, you know, for your provider type, how is it structured? Is it pay for performance, shared savings? Um, as a potential new provider to their network, you you’re you’re most likely going to have to work within their existing frameworks, right? You haven’t really proven yourself yet, so you’re going to have to do that. Um, but if they say, “No, hey, look, we don’t have any value contracts for your provider type. They don’t have anything existing.” Um, getting a contract is going to be tough, right? A payer doesn’t want to invest time creating a complex contracting structure with a net new provider that hasn’t uh proved that they can recruit or treat their members. Um, and this is why I emphasize trying to work within their framework. You know, what do they have going on? If it works for you, uh, copy paste that for your contract. for the majority of net new providers um you know if they don’t have for the I would say for the I should say this for the majority of net new providers that a payers engaging with it engaging with you know if they don’t have any valuebased uh contracts for your provider type it’s going to be hard for them uh or willing to make a valuebased contract you know for for you cuz like I said you’re a net new provider um it’s going to be very tough off. Typically for the majority of net new providers like you, peers um want you to do let’s say a year’s worth of fee for service contract prove you can recruit, treat their members, send in claims correctly, deliver good outcomes, right? And then after that uh they’ll discuss value based contracting with you, right? Um this sounds good, but you want to make sure you don’t get caught uh in what I call payer purgatory, right? So pay or purgatory, it’s the state uh where you spent um you spent time providing uh or you spent time proving that you can treat folks, right? Operating well administratively, your outcomes are good. Um and then you’re still stuck with a fee for service contract um 12 months down the line when they said, “Hey, look, we’ll reevaluate in 12 months.” And that’s when we can, you know, move you into a more friendly contract environment. And that’s that’s not necessarily them misleading you, right? Sometimes payer priorities change. They no longer can do them. Uh you know, so it can be anything, but uh but essentially, you know, you’re stuck with the rates in this contract structure you don’t want. And what I have found successful is to hedge this risk. Get the player, get the payer to define the milestones you need to hit. How many members do you need to treat over how many months, right? What outcomes? And then what’s the contract rates? If you do, what would the contract look like? Okay, if you do achieve this, this sounds simple, but it’s very it’s very hard because for the most part, payers are not are non-committal about this because, you know, their job is to see what things will look like down the road, right? They’re they’re very riskaverse. But if they don’t have any current value based contract with your provider type to hedge this risk, get the payer to define the milestones you need to hit, right? How many members for how long do you need to treat? But outcomes, so if you if you do everything right, what does the contract look like, you know, 12 months down the road? This is this sounds easy, but it’s harder. It’s hard because a lot of these payers might not have that type of information down the road, right? Um, but also they, you know, if they never done a value based contract with you or a value based contract with your type of provider, you know, they don’t even have one created. So that that requires a little work that you have to do on your end and also based on your risk tolerance, how much you’re willing to uh trust that process, but you know that that’s something I definitely recommend. Okay, super helpful information, David. Now, let’s say we had this successful conversation with the plan about a strategy to move forward with a valuebased contract. We’ve even had a year or two under our belt with fee for service. they they can see some traction already. Now, what is step one? Sure. Um, you know, like as I said before, if you’re looking for speed and they have an existing contract or similar contract with a different provider type, copy that. If a unit economic work, get started. Later, you can adjust terms um after you’ve built some trust. Uh, but the the main goal here is momentum. Get started. Um, remember, the more complex you make a contract, the more people get involved, and those are more potential. knows, like I said, just get going. Uh, but let’s say they don’t have a value based contract for your provider type, but they want to do one for you, you know, how do you how do you know what how do you know what the contract will look like? You know, um, and really what I what I think of in this scenario is um, the contract you do is the one they’re most comfortable with. So, just make sure the contract you do is the one they’re most comfortable with. So, these contracts take work. It takes effort for payers to measure. If you really save money for them, the more complex the contact or excuse me, the most comp the most more complex complex the contract again, the more work involved um and easy for them to kick a can down the road. Try this is why I say, you know, try to find what quality measure or data point they do know really well and are precise about and base the contract off of that. So, this removes the fear that they will do something wrong and the contract will be a bust for them. So um you know dris derrisk the decision by working within you know their precision if you will. So um an example would look give you an example I would think of it like this. So think of if um think of if I run an organization that provides care for folks with severe mental illness, right? We have a great company, strong patient centered model, engagement is high, outcomes are strong um and most importantly, you know, the patients also are avoiding um high costly inpatient admissions. So naturally because we in we have great deliver care, you know, we want to be compensated by the payer uh in a way that reflects the value we’re delivering. though, especially, you know, obviously the cost savings for avoiding patient care, which is always a priority. Um, that means, hey, maybe I want a shared savings arrangement. I want it because I predict it’ll make me uh let me earn the most amount of money. So, let’s say $100 per member per month. If I do a shared savings contract, that’s what I feel like I’ll be able to earn uh per member per month. Uh the challenge is shared savings contracts are incredibly complex to execute. um especially when you’re a new provider or working with a payer that hasn’t implemented this kind of model for for your provider type. Also, uh if the payer’s never done any shared savings contract for your provider type, uh then then you’re you’re in a really tough spot. And so this is why I recommend uh you know, zoom out and look at the problem through a more practical lens. It’s like is there a simpler way to reach the same financial outcome uh that $100 per member per month that you want to earn by anchoring it to a data point the payer already knows and trusts really well. So for example um maybe the payer knows that when they look across their smi severe mental illness population 25% of them are hospitalized right at least once per year right that’s a metric they they’re tracking and they feel confident about from there you can propose a structure that um hey look if I keep my inpatient uh admission rate under 25% um I receive a defined payment or a bonus right enhance rate or uh whatever may be, but it basically levels you up to that $100 per member per month. So, if you if you reach below that 25% and let’s say uh at the end of the year, you get $100 or maybe um you break it down to where you it’s a percentage of the fee schedule that gets increase that is baked in that gets you to the $100. So, you’re still getting that $100 at the end of the day, but you’re just getting it through different paths. Um you know, sure, this isn’t technically shared savings, but it achieves a similar outcome, right? you’re you’re you’re aligning the financial incentives to reduce utilization and and and at the end of the day, right, it’s much easier for the payer to implement because you know the metric is already familiar and and measurable. And um the good news is, you know, as you execute on that simpler contract and demonstrate performance and you build that trust, uh that opens the door to be to more sophisticated models down the down the line, right? You you might evolve to a full shared savings later. Um, you may also, you know, also as you build trust, you’ll get better referrals, access to, let’s say, new member populations or maybe you get introductions to other sister plans and other markets, right? These health plans are big. They they they cross a lot of different geographies. though I mean I would say the real the key takeaway from from here is uh start with something the payer already understands and can operationalize deliver result and then use that foundation to move into more um let’s say advanced contracts or move into let’s say just contracts that pay you more money right anything to derisk the situation um it’ll add more comfort and better outcomes of course really great. So you talked about more advanced situations even more than where we are at this point in our valuebased care journey. Of course I have to ask how do you take the next step to that into an even more advanced value based care model. Sure. So yeah, that that’s yeah, so this is basically, hey, great. You you’re contracted. Let’s say you you were getting these that $100 average per member per month through some type of bonus or whatnot. Now you want to like again take take the next step, get more risk um so you can earn more money. I think to really make this clear, let me define a shared savings. So um and then I can get into it because I know this helps me always help me. I know we talk about things like the hobbyists um and maybe perhaps the listener some of the listeners might not be clearly uh clearly understand what what it is. So I think this might help. So the idea behind like a shared savings contract is you know if you deliver care more efficiently let’s say fewer emergency room visits hospitalizations um and if that reduces the total cost of care right the health plan agrees to give you a percentage of those savings. Um but also typically in shared savings contract there’s something called also a quality gate, right? So you only get the share of those shared savings if you hit certain quality targets. So that’s that’s a health plan’s way of making sure you’re not cutting corners just like to save money, right? So one one common quality gate in in the in the behavioral health space would be uh the heat measure IET initiation engagement um in substance use disorder treatment. So more or less someone gets um discharged from the from the hospital or some inpatient settings because of a um an SUD diagnosis. How quickly can you get them into care? You know, the data shows the quicker you get people into care uh the better they’re going to be. So that would be an example of uh you know, a quality gate. Uh but really um if you if you want to move into a complex arrangement like the shared savings model or or um anything a bit more complex I think the key questions you need to ask are you know what’s the benchmark right h how will a total cost of care uh baseline be calculated right is it going to be prior years is it going to be on a cohort basis um this all has different implications to the math right is it going to be risk adjusted for acuity age diagnosis is um and and and that that will um uh that will really inform you to see how much money there is there to potentially save, right? So um also, you know, what’s the quality gate? Are they going to want to do heat measures? Which ones exact exactly? Um what type of threshold is there going to be to meet those uh those those savings? So sure, let’s say you have to reach the average quality measure is 20%, you need to be just over 20%, you need to be 25% plus, right? figure that out. Um, if you also will you get paid only if you hit those quality measures? Could you potentially get paid partial of those shared savings if you only hit some of them? Um, and also, you know, how how is shared savings going to be calculated, right? Is there a minimum savings rate before savings begins? Like, let’s say the first 5% of savings, right? They just hedge that saying maybe that’s just cost variability. you’re not going to get the first 5% of savings but you will get let’s say you know the percent of savings after that so and also are share are the savings going to be shared equally right is going to be 50/50 is it going to be a tiered model right these are key questions also I would talk about the attribution model are members going to be assigned to you literally is it going to be you’re are you going to be a get a list of members is a does a member get attributed to you after you have a certain amount of encounters you know with them um and also reconciliation timeline like when will we know uh if you met the cost or quality targets are they even providing you internal data throughout the year so you can see okay I need to let’s say turn the dial and improve these things um also data is important so like hey if you’re going to have to hit certain type of quality measures you know are we going to get a feed or are we going to get a member roster you know every day every week you know so we can follow up with these people cuz you want to have you know workflows in place make sure you hit those quality measures cuz you’re putting in all that work to hit the quality measure and then eventually you know get the um uh get the savings and then you know how much risk is involved is downside risk um required right are you going to have to owe money back if costs go over that benchmark um and then uh also then lastly I’ll finish up with this is you know how are outliers handled we we all understand that you know the top 20% of people are responsible for 80% of the cost or what whatever whatever it may be you know I always recommend you know can we carve out the top 3 to 5% of cost uh of members high cost members because you know you might do fantastic across the whole population but there are three people who you know you know fell off a cliff right and and was in the hospital for 9 months and that that threw everything off so these are all little things that you know you’ll discuss with the health plan and also I always recommend are things you come out the gate uh before they give you uh you know a a uh you know their their thoughts on it. I would say hey look here’s a good structure that we would like for this and typically um it’ll speed up things cuz health plans are busy and if you come at them with a pretty good structured uh contract that kind of checks all their boxes as far as the things they’re thinking of and the only thing they’ll have to do inside those boxes maybe tweak a couple things. uh hey look maybe the quality measure is this instead or maybe the shared savings is two two or three percent less uh more or less than that you know it just gets you going so yeah when it comes to contracting complexity um you know those are really you know the key questions I would ask a payer u and then once you have that information uh you should be good to go just like that good to go you make it sound so easy no no yeah it’s uh yeah it’s definitely a challenge but it’s fun you know it’s uh Like I said, you know, there’s just a bunch of key questions you have to ask. These are these are some of them you’ll ask and and I think once you get these answers, really the answers will direct you to the next steps you have to take, right? Like I always said, like why I started the course, the goal was to demystify the contracting experience. It’s not a linear experience, right? You don’t just start from A and end up to Z in this um really clear way. It’s it’s often back and forth, but you know, if you ask the right questions um and get those answers, uh you know, it’ll help you lead you down the correct path. And for folks listening, you know, as you can tell here, this is an indication of how indepth and and detailed the course is. So, I I highly recommend it. And of course, we’ll include a link for everybody in the show notes. But David, I I really thank you so much for sharing your expertise with us. This was so helpful just from start to finish that whole journey of a behavioral health provider contracting with a payer. And for those who like what you heard today, we have tons of content about valuebased care contracting, payer provider partnerships, and in fact, that’s the name of several of our tracks and programs at the 2025 behavioral health tech conference. So, of course, save the date, November 11th through 13th this uh fall in San Diego. Excited to see all of you there, including David. So, thank you so much. Yeah, thank you.
In this episode, David Ricupero, Director of Business Development at Affect Therapeutics and Creator of the Out-of-Pocket Course: How to Contract with Payors, explains the full journey of payor contracting, from initial applications to advanced value-based agreements. He covers how to join payor networks, manage closed systems, and prepare key documents and timelines. David explores various value-based care models, illustrating how risk and complexity grow from pay-for-performance to full capitation, and highlights the importance of combining traditional applications with strategic conversations. He also offers practical tips for avoiding “payor purgatory,” identifying payor goals, and asking the right questions during shared savings negotiations.
Tune in and learn how to navigate the nuances of payor-provider relationships and set up sustainable, rewarding contracts that truly expand access to care!