Managed Care Contracting

Approach to Managed Care Contracting

Our approach to contracting is strategically focused.  We believe that an effective contracting process involves the data analysis to understand how claims are being paid currently, the administrative issues encountered with a payer, and evidence of Market rates available.  We will review the providers current contracts to ensure maximum reimbursement, effective contract language, and appropriate market place.

Contract Review Process

  • Prepare matrix of all existing agreements and reimbursement rates to determine average discounts given.
  • Review service line in an attempt to include all components in final agreement.
  • 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.

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.  While the client can choose to be involved to the degree desired, SHP usually conducts payer negotiations directly with the payer, and then informs the client as to outcomes, recommendations, and next steps.  In addition, SHP typically maintains all current agreements and owns the process of validating contract performance and initiating negotiations/re- negotiations.

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 contracting strategy and approved by Client.
  • Prepare matrix of significant contract language.

Are you are maximizing reimbursement?

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