Gain a Revenue Cycle Advantage with More Effective Contract Management Brendan Kreter Solutions Engineer
Agenda Pressures in the Industry Snap Shot of Reimbursement Payment Compliance Claims Contract Profitability Contract Negotiations Negotiations Profitability Denial Analytics
Pressures in the Industry Issue: Healthcare costs continue to rise year over year, while reimbursement from large volume government payers Medicaid, Medicare, and Tricare remain on a down trend. Solution: Maximizing revenue under evolving payment models
Snapshot of Reimbursement Past : Evergreen; % of charge and per diems Present: Traditional fee-for-service Payment based on volume Cost Based Prospective Payment System Capitation Self Pay Future: Commercial & Government move to Value Based Reimbursement
Claim Adjudication-Revenue Recovery 20% - Health Insurance Providers Process 1 in 5 claims incorrectly (AMA) 41.4 % Contracted fees were improperly paid (AMA) Millions of Dollars Can Be Recovered Year over Year Plan and gather Analyze and Audit Payment Compliance
Planning and Gathering Reports at Org/Contract/Clause Level Ability to drill down to the patient level Incorporate costs for Payer/Clause level P&L
Planning and Gathering Reports at the Patient Level Depicts exactly how a claim should be reimbursed Line by line reimbursement Provides all necessary information for follow up Mark claims for follow up/claims tracking
Analyze and Audit Focus on areas of difficulty: Stop-loss terms Carve outs Thresholds Implants High-cost drugs Outpatient ASC /APC / EAPG Medicare Advantage HMO claims New payment methodologies
Contract Profitability Assessment
Payment Compliance Recap Action: Scheduled Reports and Monitoring Identify point person for when PC issues are discovered Schedule Bi-Monthly Meetings Develop a credible relationship with payers Come Prepared Appeal Claims based on Contractual data not a gut feeling Results: Improved Insurance Revenues Increased Collection Rates Reduction in Coding Errors Reduction in A/R Days Reduction in Cost
Contract Negotiations Evaluation Simulation Process Revenue from successful contract negotiations dwarfs the amount of dollars that are recovered by clients through underpayment recoveries. Director of Managed Care At Major Health Network
Pre Negotiation Evaluation Stage 1 Collect historical detail Stage 2 Obtain/Organize contract proposal Stage 3 Process claims against proposed rates Stage 4 Debrief & analyze discoveries
Negotiation Process Offer Know your goals Short & long term Initiate proposals Come prepared Ensure Profitability Put into action Agreement Counter Offer Compromise Concession
Negotiation Report Multiple iterations per contract Validate payer proposals Model organizations counter-proposals Insure overall increase as discussed during negotiations
Negotiating Profitable Contracts
Patient Level Negotiations
Negotiation Recap Strategic imperatives Know your Market and Competition Form an ongoing relationship with your payer Cardinal Rules to any Negotiation: If you do not ask, you will not receive If you do not deserve, you will not receive If you ask, and if you deserve, you must demonstrate why
Denial Analytics 10% of claims are initially denied 50% settled in favor of provider 80/20 Rule
Reasons for Denial Duplicate claim submission Patients lacks coverage Services bundled Benefit exceeds maximum allowable Claim missing modifiers Inconsistent POS on claim Lack of medical necessity Pre authorization missing Out of network physician
Denials Management Reduction Ensure receipt of EOB s from payer Ensure Patients Eligibility Focus not just on underpayments, but also internal opportunities Leverage Future Negotiations Language remediation Claim Rejects Incorrect information: Provider - name, address, contact information Patient - name, sex, date of birth, insurance ID Insurance - policy numbers, address Inputting the wrong codes Mismatched treatment and diagnostic code Up coding Under coding Sloppy documentation
Denial Report We are provided denial reports and attempt to address major issues during negotiations with language remediation Director of Managed Care At Major Health Network
Questions Follow up: Brendan Kreter Bkreter@KaufmanHall.com