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Value-Based RCM Presents "Managed Care Contracting Part II"

Are your In Network payer contracts reimbursing at vastly different rates for the same service?

The disparity between payor contracts is intentional and a major part of the payor strategy. In fact, many payors will deliberately change contract terms on a consistent basis to reduce reimbursement conditions at the expense of healthcare providers.

Most payers will contract with providers knowing they have/are:

  • Limited experience with payers

  • A mind-set the payer is always right so the reimbursement rate offered must be all they can get

  • No knowledge of alternate fee schedule options and revert to “fee-for-service”

  • Unfamiliar with contract provision language

    • Carved-out services

    • Claims processing timelines and inquiries

    • Renewal process

At Value-Based RCM our payer contracting experts will provide guidance with tracking and trending reimbursement variations for contracted services by payor. Our healthcare providers quickly benefit from this service, understanding whether they are being compensated fairly and competitively for services using a reimbursement method that fits with the providers objective and gains a better understanding of contract details above the fee schedule.

Value-Based RCM provides:

  • Planning session with providers to identify current contract performance

  • Evaluation of current contract terms and conditions to identify opportunities for improvement

  • Determining future payer contracting and goals

    • Initiating application

    • Subsequent status tracking

    • Credentialing

    • Fee schedule negotiating support

    • Letters of consideration, when applicable

    • Coordinating facility on-site visits

    • Clearly articulating the clinical value propositions defending higher reimbursement and negotiating lesser administrative tasks (i.e., authorizations, medical record requests etc.) as a “center of excellence”.

  • Exploring alternate reimbursement methodologies

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