Evidence-Driven Advocacy sm
From hospitals and ambulatory surgery centers to clinics and physician groups and everything in between, most health care providers can benefit from managed care contract review, modeling and analysis. This process can improve reimbursement and reduce underpayments in addition to providing relief to provider management from time-consuming research, modeling, analysis and negotiations.
B&D Consulting professionals have decades of experience in the health care industry, including managing complex contracts for leading health care systems and hospitals. They conduct financial modeling and analysis of managed care contracts, including both prospective and retrospective modeling of rates to determine expected reimbursement.
Services by B&D Consulting's managed care contract review team include:
- Contract Review and Analysis
- Review and analyze of terms and conditions — One requirement for accurate financial modeling is a thorough understanding of the terms and conditions in existing and/or proposed rate amendments. These can include service definitions, payment ranking systems, chargemaster limitations, stoploss claims, carve-outs for implants and high-cost pharmaceuticals. The issue of underpayment becomes more common when contracts are complicated by multiple payment nuances.
- Analysis of managed care contracts and payer mix — We measure and compare a provider's contract portfolio to determine if current/proposed rates, terms and conditions are in line with steerage to and payer-mix of the provider; and also the health plan's market share and provider networks.
- Fee schedule analysis and comparison — We thoroughly analyze and compare a health plan's fee schedule against locality-adjusted Medicare fee schedules, providing a rational benchmark for negotiations. A common question providers have when negotiating rates, especially those with less sophisticated cost-accounting systems, is "How do these rates compare to Medicare?" Providers usually know their profitability with Medicare and use it as a benchmark. The sentence in question attempts to address this type of query.
- Contract Modeling and Revenue Analysis
- Prospective modeling — Prospective modeling is critical to successful contact negotiation. It projects changes in revenue. This information is of more value than a stated percentage "rate increase" because it accounts for a health plan's utilization of the provider's services. The projected change in revenue is determined by modeling and comparing expected payments of both current rates and proposed rates using historical claims data.
- Retrospective modeling — Retrospective modeling is auditing the performance of existing contracts. It compares actual payments to modeled payments. Analysis of a retrospective model will determine the magnitude of underpayments. It will also highlight reasons for underperformance, including contract interpretation issues and medical denials for certain services. Retrospective modeling may lead to ongoing monitoring and tracking of a health plan's reimbursement-related performance.