Modeling and Management of Healthcare Payer Contracts with Ease

On 26th Sep 2018
healthcare contract management software

Healthcare contract management and modeling can be a daunting prospect, yet it is a core function of revenue management for all healthcare organizations. As revenue pressures continue to mount one thing remains true: the extent to which payer contracts are modeled and managed directly impacts any health organization’s ability to capture revenue.

The complicated nature of payer contract negotiations makes it difficult to negotiate terms and language that benefit the provider. The numerous factors that must be managed once the contract is executed can make maximizing contract revenue challenging. Healthcare contract management must be actively managed with full knowledge of the details and deadlines. Obstacles to getting all the revenue that was negotiated can include:

  • Lack of dedicated staff to maintain contracts.

  • Inability to track and appeal chronic underpayments and improve healthcare denial management.

  • Inadequate knowledge of market rates leading to unnecessary discounts, inability to negotiate strong contracts.  

  • Internal systems that don’t track negotiated rate increases to determine if payers are implementing them.

  • Missed deadlines for negotiating new agreements.

Managing these contractual details with every payer is the only way to ensure that a dollar negotiated is a dollar paid. However, it is a time-consuming, intricate task that be nearly impossible to achieve for overworked, understaffed hospital organizations or physician practices.

Fortunately SaaS, specifically healthcare payer contract management software, delivers an answer to the problem - and a good one. It can model contracts that accurately reflect, and identify reimburse for each provider’s distinct patient population, frequent services, treatments and drugs. Healthcare contract management software is a straightforward solution to the maze of healthcare contract modeling and management.

Negotiate contracts for better healthcare contract management

Knowing one’s patient population is key to negotiating contracts that reimburse correctly for care. When contract language matches the providers profile, more robust reimbursement can be secured. It’s important to know details of delivery of care:

  • What are the most frequent chronic diseases that need to be treated and managed?

  • What are the services and treatments that are delivered most frequently?

  • Does the provider meet those needs with physicians and/or a team of advanced level providers that includes physician assistants and nurse practitioners?

Drilling down to this level of insight is necessary if a provider is to negotiate payer contracts that appropriately reimburse for its work. It results in strong contracts that serve the provider well and match patient population needs. When the details of patient care are known, a contract language can be negotiated that provides for them, instead of underperforming when reimbursing them. When SaaS software conducts contract modeling, the solution acknowledges the 30,000 foot view of practice care, but protects and reimburses for patient care in granular detail.

Contract modeling can also protect a provider from inadequately negotiating rates. This can happen when the Medicare patient population is included with the private payer population in rate negotiations. Mixing private payer patients with Medicare patient volume can create the wrong picture of the patient panel.That in turn makes it difficult to analyze exactly what the payer is offering for private pay versus the Medicare population. The solution is to implement software that will create the correct models for both private payer and Medicare patients. Once the contract is executed, the software will track and manage payments for both patient populations. The right SaaS solution will model any payer contract to calculate the expected plan allowable. As a result, every single claim will be paid according to contract.

More precision, more revenue

The beauty of healthcare contract modeling and management software is that they simultaneously reduce costs while increasing revenue for the practice. The technology itself is hardwired for savings:

  • SaaS solutions eliminate the need for organizations to purchase, install, maintain and upgrade the solutions, which consumes vital resources.

  • They are highly scalable. This enables the vendor to quickly expand the solution and the number of users to accommodate unexpected claim or coding issues.

  • They are cost effective.

Healthcare contract management software functionality is like a guard dog at the door: potential revenue thieves of missed deadlines and denials are found, while accurate reimbursements are increased. It knows what needs to be aggressively addressed to receive what is owed from every payer. When modeling contracts, the best denials and underpayments management solution pre-calculates expected payer reimbursement and compares that amount to the payment processed by the payer. It also:

  • Handles all hospital, physician, SNF, LTAC, and rehabilitation claims

  • Identifies and builds contract terms to calculate reimbursement based on one or more combinations of place of service code, ICD-10 code, CPT code and more

  • Calculates reimbursement based on place of service, patient age, diagnosis codes, length of stay and more

  • Accommodates allowances for multiple procedures or charges per single encounter

  • Models value based reimbursement based on specific payer requirements

Once the contract is executed, tracking and management is essential to revenue. It’s up to the provider’s staff to detect payer trends. Is one payer constantly underpaying claims? Does one have an unusually high rate of denials? Does the practice understand the causes and can they be fixed? The best healthcare contract management & modeling software solutions give staff the quick data they need to manage contracts and communicate with payers for fast resolution of issues that are delaying revenue. Tracking, trending and reporting should include things like:

  • Tracking episodes of care whether the patient receives it from an integrated system or group of providers.

  • SaaS calculators include all the values needed, including discharge status, HAC adjustment and more.

  • Physician fee schedules: GPCI values, mid-level discounts, discounts for co-surgeons, multiple procedure reduction and more are incorporated.

  • Expected reimbursement can be forecast.

  • Expected reimbursement for case rates, global fees and other types of multiple encounters can be linked and calculated.

Data integrity is key to revenue. When the provider’s data aligns with the payer’s requirements, successful denial management in healthcare organization increases and revenue grows alongside it. Software that streamlines and automates contract modeling and management can remove enormous administrative burdens from providers and their staff while protecting revenue. It provides the insights needed to manage contracts and gives revenue cycle management teams clear, actionable information. Provider contract modeling and management software helps you maximize revenue.

It’s time to get every dollar that is negotiated, SaaS software can save the day!

Revenue Masters is a leading provider of cloud revenue cycle technology and reimbursement services. With a state of the art payer contract modeling and management software aligned with an underpayments and denials as a service, Revenue Masters is helping providers bottom line and providing peace of mind that they are collecting every dollar they earned per their payer contracts. Contact Revenue Masters today at  (877) 591-2590 or email us at to start modeling and managing your contract with ease.