Contract Compliance & Recovery
For healthcare providers, the process of contract negotiation and/or renegotiation is at best difficult and time-consuming. The growing interest in pricing transparency, pay for performance, new bundling protocols, and revisions of adjudication rules within each contract is creating significant challenges in the administration of contracts. Your organization must be able to answer a number of questions related to your contracts, but you may not have have the internal resources to manage this process effectively. These questions include:
- Have contract elements been entered correctly in your information system?
- Is your system robust enough to manage a variety of adjudication rules?
- Is your staff coding and billing as specified in the contract?
- Are you receiving payment according to contract terms and conditions?
- Do you have effective appeal mechanisms in place that are compliant with contract terms?
ECG can assist you in ensuring that each of these questions will be answered in the affirmative. Most important, as part of our involvement with our clients, we have been able to recover millions of dollars in underpaid claims. Our contract compliance and recovery services include:
- Assessment of internal systems.
- Payment compliance audits.
- Underpayment recovery.
- Dispute resolution and litigation support.
- Tracking of renewal dates and needed changes in contracts.
ECG can work with you in a variety of roles, depending on your specific situation.
- As analyst – providing you with data on which to base your decisions.
- As mentor – suggesting options and making recommendations to your staff and management, while increasing the effectiveness of your internal resources.
- As partner – assuming full responsibility and accountability for the performance of your managed care program.
Our focus is on tangible results for your organization. Our strengths include:
- Depth and breadth of experience.
- Understanding of the culture of provider organizations.
- Strong working relationships with major payors.
- Involvement of our most senior consultants in each step of our engagements.
Selected Projects
Providing financial modeling support for managed care negotiations. Expand Minimize
ECG provided financial modeling support for managed care negotiations and served as a strategic adviser on managed care matters for several community hospitals in different regions of the country. Financial modeling support included developing the reimbursement model for the contract negotiations and performing supporting analysis as needed for successful contract negotiation. Strategic support included analyzing the hospitals’ portfolios of contracts, providing advice for short- and long-term strategic reimbursement planning, and providing specific reimbursement advice during health plan negotiations.
Serving as a strategic adviser to a multispecialty clinic and health plan. Expand Minimize
ECG served as a strategic adviser to a multispecialty clinic and its physician-owned health insurance plan. As part of our work, we developed a payor contracting strategy, which was needed to address current and foreseeable issues, promote adequate access to patients, and prevent the establishment of contracts that undermine the position of the clinic’s health plan.
Providing managed care litigation support for dispute resolution. Expand Minimize
ECG provided analytical and negotiation support to a health system for resolution of a dispute between the hospital and one of its major payors. This included performing detailed analysis of payment variances, drafting an expert witness report, providing technical support to legal counsel, and assisting with settlement negotiations. The result of this engagement was a multimillion-dollar payback from the payor.
Serving as the managed care department for a health system. Expand Minimize
ECG fulfilled the managed care contracting function for a health system and its joint venture ambulatory surgery center, which included negotiation and analytical support of all managed care contracts, strategy development, and provision of managed care operations advice.
