Managed Care Contracting
Provider organizations, including hospitals, health systems, and medical groups, are facing unprecedented challenges in maintaining financial stability in a rapidly changing industry. One challenge is to manage the increasingly complex system of reimbursement arrangements from both public and private payors. As a leader of a provider organization, you must grapple with dozens of payor contracts covering hundreds of services, each with different rates, terms, conditions, and reporting methodologies. Your concerns likely include:
- Have we been successful in obtaining the best possible rates for all services?
- Are we getting paid the full amounts that we contracted for?
- What are the service mix and margins generated by our different payors?
- Have we renegotiated rates as necessary and appropriate?
- What are we doing to ensure efficient management of the contracting function?
- Do we understand the implications of emerging trends such as pay for performance and bundling of services?
ECG has both the depth and breadth of experience to guide you in contract analysis, negotiation, and revenue capture, as well as in building fully functional internal systems. Equally important, we understand the culture of provider organizations and work effectively across all levels of the organization, from support staff to the senior leadership and the Board of Directors. Our managed care services include:
- Managed care strategy development.
- Contract modeling, analysis, and language review.
- Negotiation and negotiation support.
- Rate benchmarking.
- Payment compliance audits.
- Dispute resolution and litigation support.
- Operational review and improvement.
- Managed care structure, function, and organizational design.
In addition to these services, ECG conducts an annual National Physician Reimbursement Survey. The continuous evolution of the healthcare industry presents a challenge for providers seeking current and relevant data that offers insight on reimbursement levels and reform-related arrangements and strategies. ECG has developed a survey to collect and analyze reimbursement data and qualitative information that will help position providers to answer key strategic and business questions and will serve as an effective resource for commercial contract negotiations.Within your organization, it may be an option to have ECG serve as your managed care department. A number of clients have found significant benefit in collaborating with us in this manner.
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.
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.
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.
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.