Healthcare: managed care: hospital
Challenge:
After a period of year-over-year growth in number of managed care patients, and a corresponding decrease in overall revenue, the hospital determined it needed to take significant steps to improve its financial position.
Existing challenges included:
- Significant under-representation of faculty practice physicians credentialed in networks of contracted payors
- High levels of denied and underpaid claims for professional services rendered
- Contracted reimbursement rates below that of peers in the market
- Net decrease in revenue for faculty practice
During the initial assessment phase of the engagement, it was concluded that there was a lack of internal staff responsible for, dedicated to, and experienced in managed care contracting and health plan relationship management.
Solution:
We assembled a team skilled in financial analytics and projections, strategy development, contract negotiation and project management expertise.
The team worked with:
- Hospital leadership to develop a managed care strategy to improve the long term financial stability of the facility
- Faculty Practice leadership to create buy-in for enhanced workflows and processes, to capture, report and communicate physician credentials to health plans
They also:
- Provided regularly scheduled seminars for faculty practice physicians, ambulatory care center administrators and hospital executives on working within the managed care environment
- Developed and maintained processes and procedures documents for requesting authorizations and verification of coverage for each contracted plan
- Implemented patient outreach programs to improve compliance of annual visits for patients assigned to faculty practice physicians
- Established Managed Care Plans to continually audit, and subsequently correct, incorrect provider demographic information
- Instituted Managed Care Organizations to negotiate payment rates and terms or to amend existing contracts
- Approached Managed Care Organizations to rectify historical claim payment disputes
Results:
- Enhanced contract reimbursement for both the facility and faculty practice
- Implemented delegated credentialing to ensure timely representation of physician participation with each plan
- Increased referrals to physicians from other health plan participating providers
- Improved physician listing accuracy through regularly conducted audits of health plan directories
- Improved payment accuracy
- Reduced claim payment disputes and claim reprocessing
- Enhanced communication with health plans
- Improved physician listing accuracy through regularly conducted audits of health plan directories
- Improved payment accuracy
- Reduced claim payment disputes and claim reprocessing
- Enhanced communication with health plans
The information provided here is for general guidance only, and does not constitute the provision of tax advice, accounting services, investment advice, legal advice, or professional consulting of any kind. The information provided herein should not be used as a substitute for consultation with professional tax, accounting, legal or other competent advisers.