Managed Care Contracting

Are you maximizing reimbursement? Certainly contract language and reimbursement rates are the driving force behind a payer’s payment structure.  Therefore, Charge levels, charge capture, clinical coding, as well as billing, payment posting, and appeal processes affect overall reimbursement. Additionally, aging managed care contracts may lack mechanisms that allow for appropriate reimbursement for new services, new locations and chargemaster increases.

In the fast-paced world of healthcare management, maintaining relationships with payers and validating contracting performance can often take a back seat to day-to-day operations. Therefore, SHP strategically focuses our approach to managed care contracting. To understand how claims are being paid currently an effective contracting process involves data analysis. Additionally, the administrative issues encountered with a payer, and evidence of Market rates available. We will review the current contracts to ensure maximum reimbursement, effective contract language, and appropriate market price.

SHP offers an array of contracting services to meet your needs. Specifically including project-based work and ongoing contract support. Details about the processes we take are below.

Contract Review

  • Prepare matrix of all existing agreements and reimbursement rates to determine average discounts given.
  • SHP will review service line in an attempt to include all components in final agreement.
  • We review claim dataset to identify top payers and the most impactful agreements.
  • Review payer access to ensure discount given is commiserate with level of steerage.
  • Prepare detailed grid of terms to be addressed during negotiation and summary of top issues.
  • Perform reimbursement analysis across spectrum of payers and model against new contract offerings.

Data Analysis

  • Obtain data downloads for last 12 months of claims.
  • Analyze paid claims data by payer in order to determine percentage of Medicare allowed or other applicable base line.
  • Summarize the data and compare the results to market rates.

Managed Care Processes

  • Recommendations for contracting actions based upon data analysis, payer penetration and market knowledge.
  • Request copies of current payer contracts and reimbursement rates.
  • Perform audit of current and annual participation status in various payer plans.
  • Recommend strategic contracting strategy.
  • Negotiate contracts and reimbursement rates as defined by the contracting strategy and approved by Client.
  • Prepare matrix of significant contract language.

Ongoing Contracting Support

Our ongoing support is intended to emulate the use of an internal managed care department for the health system. Typically, we maintain payer relationships and initiate any contracting discussions. The client can choose the degree of involvement. Typically SHP usually conducts payer negotiations directly with the payer, and then informs the client as to outcomes, recommendations, and next steps. After that, SHP typically maintains all current agreements and owns the process of validating contract performance and initiating negotiations/re-negotiations.