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