“Healthcare Payer and Provider Contract Management: Payers have unique approaches to contracting risk. Providers groups also have unique preferred approaches and must understand the complexity of managing multiple types of contracts, and enter into those contracts with a clear understanding of what they entail with the recognition that a single care model applies to all patients within the organization.” — Healthcare Information and Management Systems Society (HIMSS)
We thought the HIMSS definition for above is a concise overview of the same complexity we see with SSI Group payer and provider clients. In the end, it’s all about managing information efficiently and intelligently to pay and get paid.
Provider Concerns for Healthcare Payer Contracts
From the provider side, we found some good advice at the Government’s National Library of Medicine site:
“Bob Phelan, chief executive officer of Integrated Community Oncology Network (Jacksonville, FL), a multispecialty cancer services network spanning four northeast Florida counties, explains why his network initially assesses the aggregated fees: ‘The payers try to slide the money from one bucket to another. They’ll increase E&M [evaluation and management] codes by 20%, but that’s really only approximately 12% to 13% of business. At the same time, they decrease drug reimbursement by 2%, which offsets the E&M increase. We look at the aggregate contract to analyze the payer’s overall discount.'”
Mr. Phelan explains the strategy behind some of our own offerings. To succeed in the current market, providers require access to technology that allows for accurate claim submission and rapid reimbursement. SSI Claims Director streamlines organizations’ billing practices by guiding users through the electronic claim submission and reconciliation process from beginning to end.
SSI provides an SSI EDI (Electronic Data Interchange) Gateway, which is a robust engine with customized business rules, edits, and validations specific to each payer’s needs, enabling organizations to receive claims in the exact format necessary for their system to auto-adjudicate. We’ve found that providers need to read and negotiate their contracts very carefully, then ensure that they reference the contracts to ensure they are being paid correctly throughout the year.
Healthcare Payer and Provider Contract Management Efficiencies
The Provider AND Payer Advantage: Using systems and software developed at SSI, our clients on both the provider and payer side have access to critical up-to-date information. For payers, we help optimize the flow of records from multiple sources including paper, images and clearing houses with administrative data added during the process.
For healthcare payer and provider contract management, there is a proven increase in efficiency seen with the use of electronic attachments, especially important with respect to insurance claim documentation. Electronic attachments streamline the process as CMS and commercial payers require medical necessity documentation for certain procedures or events. When supporting documentation are included along with an initial electronic claims submission, both providers and payers see benefits including fewer denials and fewer rework requests leading to an increase in ROI.