Stakeholders discuss ‘moving the bar’ with payers 

WATERLOO, Iowa – In a health care market where payer networks are getting narrower and more complicated, it’s important for HME providers to equip themselves with strategies to be noticed and heard, a panel of stakeholders emphasized at VGM’s Heartland Conference on June 11. 

“We’ve been pretty proactive about creating a story,” said James Russell, owner and vice president of URS Medical in Waco, Texas, which is part of Pediatric Home Service. “Some of that comes down to data and some of it comes down to the care we provide. We’ve looked at how we can differentiate ourselves in conversations with payers.” 

The panel, moderated by Miriam Lieber, also included Sharon Pruitt, solutions management director for Carelon, which is owned by Elevance, and Craig Douglas, vice president of payer and member relations for the VGM Group. 

A big part of URS Medical’s story is the role it plays in educating patients, Russell said. 

“It’s the standard of who we are as an industry and we do a horrible job of communicating this,” he said. 

Pruitt said it should also be about educating payers. 

“You need to show you’re not just another DME company that wants to come into the network,” she said. “You have to bring value or something interesting. Call other providers and ask them, do you provide X, do you bill insurance? Don’t assume (the payers) know (this competitive information); they don’t know.” 

Another part of URS's story is providing better care, Russell said. That’s where utilization data comes in handy. This hit home, he said, when his company lost a sole-source contract for incontinence supplies to another company that reported less than 1% of their patients had a fall. The message was clear, he said: “It’s not what data you’re reporting that matters; it only matters that you’re reporting data.” 

“It can be something as simple as breast pumps,” he said. “What can we move the bar on? Is the mom breastfeeding longer with the products and services we provide? You need to pull something from somewhere that resonates.” 

When these strategies don’t work, Russell said he looks outside his four walls. 

“We do have a full-time lobbyist on retainer,” he said. “That’s something we have found value in for challenges on the state Medicaid level. They have connections we don’t.” 

Douglas agreed: “This is important enough that you should have someone who has the time to spend on (payer relations).”