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