Negotiating Payer Contracts
Managed Care Negotiations: How does it work?
A Highlight to contracting process flow
Once we sign a client services agreement, we work with you to determine the practice strategy that fits your needs. Whether is 1-2 contract negotiations or full external management of all payer contracts, we have a proven method that is built to best serve you.
We have several collaborative tools that we use to keep our clients apprised of all contracting activities through a flexible CRM tool or bi-weekly huddle calls.
Payer Applications are a tedious and lengthy process to get in-network, we have a team of professionals that can help. From credentialing facilities, centers to providers we know what is required by health plans in all markets to remove the frustration out of doing this on your own.
Once we complete any and all documents necessary, we receive the contract from the health plan and do what we do best: Negotiate.
Our 10Phase Approach
Building your Managed Care Solution
- Build the practice portfolio
- Offices, addresses, phone numbers – what we share with the payers
- Building the payer specific elements
- Tax ID’s, NPI’s, PTAN’s, Medicaid #, Provider Rosters
- Draft your managed care repository
- SharePoint, MS Teams, etc. to manage and organize payor agreements
- Determine the Practice and Payor Data
- Patient volume, payor mix, missing contracts & fee schedules
Retrieving Managed Care Agreements
- Converting all agreements to electronic copies, locating fully executed agreements & compiling list
- Reviewing existing agreements, advising on both language implications and reimbursement rates
- Obtaining Fee Schedules & updating repository of financial elements tied to agreement.
- Pinging payers on new or existing agreements, sharing provider portfolio’s and establishing rapport with the market leaders
- Launching applications or requests to join the network for new agreements
- Completing necessary applications and paperwork to obtain managed care agreements
- Starting the dialogue with payers on either new or existing rates
- Comparing benchmark payor data and negotiating optimal reimbursement rates
- Reviewing and negotiating payer language and implementing contracts that fit the operations of your team and protect your organization
- Taking final offer rates from payer and comparing against previous reimbursement
- Drafting an analytical model to provide practice visibility into the outcome of negotiations and impact on budget
- Comprehensive reporting & dialogue with practice to ensure rates and language agreed upon work for the budget and operations of the practice
Preparing Fully Executed Documents
- Routing managed care agreements to the signature authority of each party, unless authority of the practice has been delegated to Payr Advisors
- Providing a financial impact summary to revenue cycle and creating expected pay mapping tables* to ensure revenue integrity
- Logging fully executed agreements in repository folders
Post Execution Phase
- Drafting final documents to ensure payors have necessary compliance documents, payment tables, demographic listings, and all completed necessary exhibits pertaining to the contract
- Creation of current provider rosters and data necessary to load payor tables
- Credentialing of providers and centers* with payors
Maintenance of Your Contract Portfolio
- Building internal documents and storing of managed care agreements
- Reporting files on specific / key payor elements within agreements such as termination dates, reimbursement specifics, credentialing and timely filing requirements, etc.
- Mapping of expected pay* to ensure your ERA’s are receiving the allowed amount
Management of Payer Operations
- Assisting prior authorization teams on improper denials and benefit eligibility determinations
- Adding new locations & supporting growth efforts by amending existing contracts, affiliating locations, etc.
- Working with revenue cycle to escalate payment denials and overpayments to payor
- Ensuring payor contract rights are enforced and payors as well as providers adhere to contract responsibilities with compliance reporting
Managed Care & Beyond
- Creating opportunities to discuss continued growth & partnership with Payors including site of care redirection initiatives
- Discovering opportunities for Value Based Contracting and alternate reimbursement mechanisms
- Working with your revenue cycle, prior authorization and clinical staff teams to ensure optimal performance