What Randy Cook really meant was to bring forth a few — powerful — sheets of paper.

The Tennessee-based consultant told medical practice managers — recently here for the Medical Group Management Association conference — that some strategy and number crunching can give them much more leverage in negotiating with insurance carriers.

"There is a tremendous amount of power you have," he told the audience at the Las Vegas Convention Center session. "Even if you're a single physician."

Cook, who works for medical malpractice carrier State Volunteer Mutual Insurance Co., told the managers to position themselves so they can afford to lose an insurance carrier, or at least afford to reduce some of the business it does with a carrier.

Insurance negotiations can be the difference between bread-and-butter and stale, old bread for a practice's balance sheet. Inflation and rising medical costs must be balanced with how badly a practice wants access to patients covered by a certain insurer.

Cook told practices that their power derives from how busy a practice is. If the practice is in high demand, it can drop an insurance carrier or reduce some services with confidence that other patients will fill in those holes.

To track this, a manager can look at the appointment book or at typical wait times.

If the office is busy, Cook advised to find which insurance carrier pays the lowest rates. Dropping that carrier might make room for patients from higher-paying carriers, which would increase overall revenue.

"If you can say, 'I get $60,000 more a year if I don't do business with you, you have tremendous power,'" he said. "And you can know that before anyone."

If a low-paying carrier is a Goliath in the market, and the practice would crumble without that carrier's patients, a practice can still play some hardball, Cook said.

"Can I reduce how much business I have with them?" he asked the audience. "Only take five of their patients a week, and the sixth one gets seen next week."

One downside, though, is that specialty practices using this strategy might sour a relationship with a primary care provider who refers its patients.

Either way, practices should anticipate the insurance representatives to act negatively. But the key is to stick with the numbers and keep from getting emotional, he said.

"You can't make stuff up," he said. "You have to do the work, but when you've done the work you're in a position to respond."

If the medical practice is not in a position to drop services, Cook recommended taking steps to increase market share. Offer a service that is unique to that geographic location, or do marketing to make more patients choose that office.

The most common opportunity to make a practice busier is when a physician retires, he said.

Flipping to a PowerPoint slide with the headline "Working Less and Making More," he showed that a practice that is not overbooked could give each remaining physician a few more appointments. The remaining doctors are all making more money than when they shared it with the retired doctor.

That would put the practice in a better position to threaten to cut insurance carriers or programs.

"If they can adjust excess capacity, reimbursement rates can go up," he said. "A doctor is working 10 percent harder, but can get a 12 percent increase in pay."

The alternative, recruiting another doctor, would cost money and would not improve demand for the practice — only bring it back to the former level, he said.

Cook gave all conference attendees a free CD-ROM with tools to help them achieve these goals. The discs are free to the general public, he said. E-mail him at rancyc@svmic.com or call (615) 846-8354 to order one.