Real time financial data and transparency in healthcare contract management

On 13th Dec 2018
hospital contract management transparency

Data runs rampant in healthcare. However, when it comes to healthcare contract management, the question is, how do you get the right data at the right time to achieve optimal reimbursement? Getting data in your hands in real time is the only way to get a clear picture of practice reimbursement and payer contract compliance. Without it, contract managers, administrators and providers can’t clearly understand revenue flow - and revenue obstacles. The fact is, in an industry where transparency is hard to come by, real time financial data can make healthcare contract management clear as a bell instead of a clouded, uncertain landscape.

The complexity of payer contracts demands real time data.

Knowing the details of payer contracts puts powerful information in your hands and can grease the wheels of revenue. However, that can be a time intensive task. Tracking and managing contract details, renegotiation dates and reimbursement rates alone is a task far beyond manual systems. There are myriad details in each payer contract, multiplied by the number of payers and plans in most hospitals or practices. Any given payer contract can contain:

  • Complex and specific qualifiers for reimbursements rates

  • Complex stop loss, including dual stop loss

  • Custom DRG’s with specific rules

  • Blended reimbursement rates

  • Value base

  • Bundles

  • Auto increases

  • Custom fee schedules, which can update monthly

  • Timely billing and appeal limitations

  • APR-DRG and EAPG with customized rules

  • Specific billing rules

  • Claim dispute procedures

Transparency is essential, and hard to come by; automation can help. Only a system built on transparency can tell you in real time what is being paid when, track claims, underpayments, denials, and contract based reimbursements. When a delay in payment can be seen immediately and when automated notifications show terminations, the provider suddenly gains control over RCM.

Revenue cycle management tools that provide real time data empower RCM managers, administrators and providers to eliminate delays and enhance healthcare revenue recovery. It’s important to know that the best systems on the market provide real time data while allowing you to keep your current healthcare claims management workflow. The systems can be integrated while at the same time adding auto-calculated underpayments and denials to boost net patient revenues.

Automation manages multiple contracts

The ability to view all contracts in a central location provides critical control over important details. No one person or manual system can track contract compliance for numerous payers. Healthcare contract management systems:

  • Store and track all documents

  • Notify staff of important dates for compliance, regulation

  • Streamline work by ensuring adherence to contract terms, removing delays and missed deadlines

Automation delivers knowledge to RCM staff:

  • What you should get paid with combined payer contracted rates

  • Denials - both remit and invisible denials

  • Underpayments - as soon as they happen

Here’s another important detail about automated systems; beware of 835 remits. 835 remits reflect the payer decision to pay or not to pay. That doesn’t always deliver to the providers all the information they need because payers use dated rates, don’t update renegotiated rates, downcode claims inappropriately and have other deficient practices. As a result, the 835 remit sometimes reflects inaccurate data. In other words, it’s an error on an error. The best RCM systems show you exactly why claims were denied and the actions you need to take to overturn the denial. That’s transparency that turns into dollars.

Avoiding missed revenue opportunities

Revenue integrity should be a given in every practice but it’s not. That’s because it requires timely financial data and transparency into RCM functions. It means having the information necessary to find missed revenue opportunities, potential coding compliance errors and reduce the costs of incorrect original billing. Healthcare contract management systems that offer MS-DRG pre-billing risk analysis are your best partners in this endeavor. They provide important functions:

  • Analyze pre-billed MS-DRG based on predetermined qualifiers

  • Automatically flag claims that are likely to have MS-DRG validity

    • Missed revenue integrity opportunities

    • Potential coding compliance concerns

  • Provide a narrative to guide coders on the reasons a claim was flagged

A healthcare payer contract management system provides Revenue Cycle Management staff with the financial data they need, based on transparency into the core functions of the RCM function. It’s a window of opportunity providers cannot afford to miss.

The power of speed

When it comes to capturing lost revenue, speed is of the essence. Knowing a claim has been denied provides the opportunity to appeal within the given window of time. Notice of underpayment can result in immediate notification to the payer and recovered revenue instead of long, drawn out delays and lost revenue. Two important tools can give you rapid information to healthcare revenue recovery:

1: Mobile apps: When you have powerful trackers in the palm of your hand, there is no delay to kill revenue. Dashboards show how many claims have a payment variance and how many of those are underpayments or denials. You can see how much revenue is outstanding, monitor volume and revenue in appeal status and see the total revenue received overall. It is the most advanced method for tracking payment variances and overturning them  

2: Payment Variance Reporting: The need to leverage data and analytics is becoming more essential as risk-based contracts become increasingly complex and challenging. Payment Variance Reporting delivers the pillars of real-time, transparent information with clarity on the payment variances that need to be recovered. It can identify:

  • Underpayments

  • Claim level denials and root cause

  • Invisible denials

  • Administrative and technical denials

  • Net revenue claims forecasting based upon contractual allowable vs bucket or historical forecasting

  • Historical and open payment variances for payment recovery

  • Analytics for payer contract negotiations

Transparency is hard to come by and revenue integrity can seem like an impossible goal. However, the right healthcare contract management software can be integrated into the practice and quickly deliver actionable financial data, and transparency into contract compliance and reimbursement. With the move to value based care and risk-based contracts, there is no time to waste. Obtaining the best healthcare contract management, that also offers full transparency, now means revenue recovery and protection for every dollar earned.

Revenue Masters SaaS platform offers full transparency into contract management & modeling for 100% collections. Revenue Masters also offers a mobile app for tracking collected vs. collectable revenue 24/7. Click here to learn more about Revenue Masters, contact us today at (877) 591 2590, or email us at