Payor Contracting

Managed Care Contract Checklist

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You've taken the time to answer the question of "What is a managed care contract?" and fought hard to secure a managed care contract with favorable terms, but what happens after acquisition? Implementation is a period fraught with challenges. As you integrate new contractual requirements into existing workflows, you'll need to be sure to implement processes that reduce risk and limit liability. The steps outlined on our managed care contract checklist are not comprehensive, but they will serve to help your organization begin the implementation process after contract acquisition.

#1. Integrate Claims Processing Provisions

First on the managed care contract checklist is integrating claims processing provisions. The claims processing provisions in your managed care contract must be integrated into your claims processing workflow. Doing so will ensure claims are reimbursed promptly, payment accuracy is improved, and money isn't left on the table. Pay close attention to the clean claims submission requirements in your managed care contract. Clean claims are considered claims that require no additional documentation for reimbursement. As a best practice, integrating clean claim requirements into the claims submission process will allow a provider, or physician, to generate more clean claims and result in fewer rejections over time. This will ensure you maximize the benefit that your managed care contracting is providing.

#2. Ensure Regulatory Compliance Requirements Are Met

Managed care contracts often contain requirements for providers to demonstrate regulatory compliance that is consistent with the network of the managed care organization (MCO). What is a managed care organization? It is an organization that works with healthcare providers to provide care for members at reduced costs. If your MCO contract stipulates that you'll need to demonstrate Health Insurance Portability and Accountability Act (HIPAA), Health Information Technology for Economic and Clinical Health Act (HITECH), or even Payment Card Industry Data Security Standard (PCI DSS) compliance, implementing regulatory compliance measures should be a top priority. A provider must not only ensure that regulatory requirements are met, but that data collection efforts match compliance reporting requirements. Additionally, regulatory requirements must continue to be met over time. Achieving that outcome will require ongoing compliance review and auditing measures.

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#3. Automate Processes Where Possible

Effective managed care contract management is a challenging task, particularly when contract management processes are executed manually. Under a value-based care contract, automating processes through a unified contract management system is becoming essential. Profitability under a value-based care contract demands a unified approach to contract management that occurs throughout the lifecycle of the contract. This is made more difficult by the sheer number of contracts that some healthcare providers carry. Utilizing a centralized contract management system can help:

  • Improve payment accuracy
  • Minimize risks
  • Provide full audit tracking
  • Automate contracting tasks
  • Improve your position during contract negotiations

#4. Understand Your Terms and Termination Requirements

Immediately after negotiating managed care contracts successfully, it may seem that the terms and termination clauses in your contracts are on a distant horizon. While that may be the case, it is crucial to understand exactly how long your contract terms last and what events can lead to early contract termination on the part of either party.The information can be used to guide strategic decision-making. The termination terms in your managed care contract should be carefully read and understood so that you can implement processes that align with the contractual requirements and avoid early termination. At the same time, understanding your contract terms is essential for driving growth, implementing new operational procedures such as data collection and monitoring, and informing your subsequent contract negotiations.

#5. Expand Your Contract Management Team

Value-based contracting demands a unified, comprehensive approach to contract management. That simply isn't always possible for providers, many of whom are struggling to meet the dual demands of value-based care; a higher quality health plan, or care, at lower costs. The good can expand your contract management efforts with our team at PayrHealth. PayrHealth offers a comprehensive suite of managed care contract services, including a comprehensive contract management system and a team with decades of experience negotiating favorable managed care plans and contracts for providers. Outsourcing to a third-party managed care contracting solution gives providers the flexibility to maximize the growth potential of their contract portfolio, without the need for costly investments in personnel and technology. Whether you're looking to negotiate more favorable rates, expand your patient base, or negotiate a new contract in a tough market, our team at PayrHealth can help!

Closing Thoughts

The post-acquisition period following a successfully managed care contract negotiation is a critical time for laying the foundation to drive growth and maximize the benefit your contract can provide. Following an acquisition, providers will need to integrate contractual requirements with their existing workflows. Top priorities are to ensure your organization is meeting regulatory compliance requirements to limit operational and financial liability, and integrate claims processing provisions to boost clean claims and create more accurate payment processing workflows. Though post-acquisition can be a period of rapid change, it also presents opportunities. Making the most of those opportunities may require a unified contract management solution. If you're ready to maximize the potential of your value-based contracts, but aren't prepared to develop a comprehensive contract management solution in-house, our team at PayrHealth can help. As your partner, our specialized managed care consultants will work closely with you to ensure you're getting better rates during contract negotiations. We'll help you negotiate new contracts, build your patient base, and expand intelligently. If you're ready to take the next step in value-based care, reach out to us today!


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