The goal of healthcare providers is to render quality care for reasonable reimbursement that will support the long-term viability of the organization. Gone are the days of "provide quality care and the dollars will follow." Today many payors seek to reduce medical costs through price management. To survive, the provider must create a framework for contracting decisions. Otherwise, margins will deteriorate and the mission will cease. We provide a variety of services designed to better prepare and negotiate contracts that serve the interests of the provider.
Payor Strategic Assessment
Understanding which payors are most important to the market and whether or not the payor's reimbursement allows a margin on its block of business is critical to the survival of the provider organization. We help our clients develop an understanding of the market, review historical payor relationships and trends, determine the profitability of current contracts, revise denial management activities, develop pricing models for core and non-core services, and implement a payor strategy for the local market.
Provider Contract Negotiations
In managed care contract negotiations, what you don't know can kill you. It is imperative to research the payor's position and prepare for the negotiating sessions. We help by reviewing a payor's market position and rate filings to determine information useful to achieving a provider's objectives. We discuss the historical relationship to determine the specific needs and objectives for the provider organization. Establishing ranges for settlement is critical to maintain a margin on the payor's block of business. We'll ask the critical question that must be answered before negotiations start, "Can you afford to walk-away and become non-participating?" We determine arguments and counterarguments to increase our client's bargaining power. We evaluate the specifics of the agreement to reduce ambiguity or misunderstanding. Then, we serve as lead negotiator or team member to negotiate the deal.
Payor Compliance Audits
Recent mergers of managed care companies are creating mega payors intent on reducing the medical costs to its members. Most of the pressure has been focused on the reimbursement to providers. However, experience has shown that many payors have historically and continue to have significant payment errors. Over time these errors result in tens of thousands dollars of underpayments to providers. Our services are designed to analyze contracted payor's reimbursement and adjudication practices to identify opportunities to correct payment errors.
We use a multiple-task approach that is designed to test a payor's accuracy and recover underpayments. We work with management to identify payors that present or suspected of payment problems. We conduct a thorough review of the payor's agreement to determine the recovery opportunity window. We then audit the eligibility, claim, denial and payment data to identify patterns of error and work with the provider to prepare supporting documentation. Finally, we work with payor to recover underpayments.
Representative hospital audits included a hospital with approximately ninety-five million dollars in annual revenue, wherein the audit of a single payor for a single fiscal year resulted in recovering $250,000. An audit of a university-based physician hospital organization (PHO) that was globally capitated for medical services to 30,000 members resulted in a recovery of approximately $600,000.