Payor Contracting 101 for Private Practice Physicians

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Practicing physicians encounter a wide variety of contracts for payment for their services. The American Medical Association (AMA) has published a payor contracting toolkit, which provides an overview of payors and outlines common insurance products and reimbursement structures. The health care landscape is changing rapidly, driven by payment reform, regulatory changes, technology and consumer demands, among other factors. 

For physicians considering private practice and for those who are already working independently, the AMA provides resources to contribute to the success of this model of care.

Current state of private practice

Learn more about the current state of private practice.

• View the AMA's What makes a high performing practice? webinar
• In a challenging landscape, there is new support for private practices
• Policy Research Perspectives: 2020 Physician Benchmark Survey (PDF)

Evaluating practice arrangement options

Identify, learn about and compare practice settings.

• STEPS Forward™ Toolkit: What to look for in your first or next practice

Emerging payment models

• Physician payment & delivery models
  • • Evaluating Medicare Advantage Value-Based Contracts (PDF)
    • Evaluating Medicaid Value-Based Care Models (PDF)
• Physician payment resource center

Health plan/employer contracting considerations

Learn more about contracting considerations for a private practice.

• Payor Contracting 101 (Webinar)
• Payor Contracting 201 (Webinar)
• Private Practice Toolkit: Payor Contracting 101 (PDF)
  • Private Practice Toolkit: Payor Contract Review Checklist (PDF)
  • Private Practice Toolkit: Payor Contract–Sample Contract Language (PDF)
  • Private Practice Toolkit: Examples of Significant Payor Unilateral Policy Changes (PDF)
• Managed Care Legal database
• Physician-employer engagement: Direct-to-Employer arrangements
• Physician Only ACOs: An Opportunity to Consider (PDF)
• Pay-for-performance contracts (PDF)
• Evaluating bundled or episode-based contracts (PDF)
• Developing Clinically Integrated Networks and other Innovative Contracting Models (Webinar)
  • Related resource: Clinically Integrated Network (CIN) checklist (PDF)
• Cutting Edge Trends in Physician Compensation (Webinar)
  • Related resource: Ancillary Services checklist (PDF)

Partnering with a hospital/health system/ACO

Many physicians have the option of affiliating with or being employed by a hospital, health system or an ACO. Explore key issues and more.

• Key issues to consider when forming an ACO with hospitals
• Accountable Care Organizations: How to Perform Due Diligence and Evaluate Contractual Agreements (PDF)
• Should your practice join a hospital ACO? What to consider
• How to Evaluate Contractual Agreements: Unwinding Existing Arrangements (PDF) 
  • 5 keys for physicians unwinding contractual arrangements

Partnering with a private equity firm or seeking venture capital funding

• Venture Capital and Private Equity Investment (PDF)

Regulatory and legal considerations

• Trends in Payor Audits and Disputes, Part 1 (Webinar)
• Trends in Payor Audits and Disputes, Part 2 (Webinar)
• Payor Audit Checklist (PDF)
• A Brief Summary of the Stark Law and Anti-Kickback Statute Reforms (Final Rules) (PDF)
• Stark waivers in the PHE
• Strengthen the practice resource guide is designed to help physicians, legislators, attorneys and others identify many of the benefits and limitations of several potential collaboration arrangements.