Negotiating with Commercial Payers Takes Planning, Strategy

Ms. Jefcoat addressed the development of the ACR Value-based Payment Model pilot that touches on several different areas, including:

• The promotion of evidence-based guidelines that include meaningful quality measures and targets,
• A gold card program for prior authorization that eliminates prior authorization if a practice meets certain criteria,
• Tailored support to primary care providers to improve network referrals,
• Expanded access to rheumatology care with the use of telehealth and advanced practice providers,
• A shared savings model that includes claims cost benchmarking and a sharing percentage, and
• Data sharing reports shared regularly with practices.

Vanessa Caceres is a medical writer in Bradenton, Fla.

References

1. Mannion ML, Xie F, FitzGerald JD, et al. Changes in the workforce characteristics of providers who care for adult patients with rheumatologic and musculoskeletal disease in the United States. Arthritis Rheum. 2024;76:1153–1161.
2. American Medical Association. Medicare physician payment continues to fall further behind practice cost inflation. January 2025. https://www.ama-assn.org/system/files/2025-medicare-updates-inflation-chart.pdf.
3. Emerson J. Hospitals are dropping Medicare Advantage plans left and right. Becker’s Hospital Review. Sept. 27, 2023, updated Nov. 14, 2023. https://www.beckershospitalreview.com/finance/hospitals-are-dropping-medicare-advantage-left-and-right/.
4. Emerson J, Casolo E. 33 health systems dropping Medicare Advantage Plans. Becker’s Hospital Review. Oct. 16, 2025. https://www.beckershospitalreview.com/finance/20-health-systems-dropping-medicare-advantage-plans-2025/.