Many healthcare providers are not equipped with the sophisticated software or appropriate staffing levels necessary to translate each managed care contract and calculate accurate reimbursement. But, with the escalating complexity of contracts, this function is more vital to hospital operations than ever before.
CBIZ has the expertise to enhance managed care payments through expert negotiation, financial assessment, contract language review and review of administrative and medical denials.
Managed Care Contract Negotiation Services
CBIZ offers both hospitals and physicians a variety of expert managed care contracting services that employ proven contracting strategies and tools. Our financial expertise allows us to offer two levels of assistance:
- Development of Strategy and Oversight: Our professionals develop an individualized contracting philosophy, including the identification of key payers to contract with, competitive issues driving the need to contract, evaluation of the employer environment to determine the level of need for contracting and the evaluation of the physician environment to identify future contracting opportunities and pitfalls. CBIZ also provides a variety of analyses prior to and during negotiations, which permits providers to assertively negotiate managed care contracts and evaluate the competitiveness of their rates compared to competitor benchmarks and hospital cost levels.
- Outsource Negotiation: Under this option, CBIZ manages the entire negotiation process with minimal interruption of the finance workflow. CBIZ directs all meetings, data collection and analysis, and is responsible for delivering final rates.
Managed Care Payment Audit
With the continued growth of managed care, both negotiating and monitoring managed care organization (MCO) contracts is becoming a greater burden for hospitals. Managed care contracts represent an increasing share of hospital revenues, yet many hospitals are not equipped with the sophisticated software required to quantify the impact of each contract and calculate accurate payment levels. Studies performed in mature managed care markets claim that underpayments from managed care payers average from 4 percent to 8 percent of net revenues.
CBIZ has developed the managed care payment audit to identify and recapture underpayments from MCOs and unauthorized preferred provider organization (PPO) discounts. The audit provides hospitals with powerful computer capabilities to monitor and analyze the increasing number and complexity of contracts. Our service enables providers to identify managed care payment variances by calculating entitled payments by payer at the patient level, based on each payer's contract provisions. We then compare payments with the actual cash received, which assists in recovering lost revenue.
Important capabilities include:
- Detailed contract compliance studies: Our studies include verification of payment levels, identification of carve-out levels and determination of service definitions used to drive payments.
- Denial reviews: Our services include both the appeal of current medical and administrative denials and the performance of a process improvement program to reduce future denial levels.