Strategic Payer Contracting

Overview

Despite its critical role in driving on-going performance and facilitating strategic scaling, payer contracting is commonly one of the more opaque departments within the physician platform ecosystem. As practices scale and payer contracting becomes an increasingly overwhelming task, practices frequently submit to unclear performance reporting and ambiguously defined goals.

However, given its importance and technical nature, we believe payer contracting requires a precise approach: invest in qualified oversight and transparent performance reporting as well as clearly, realistically, and proactively defined strategies.

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Our Process

  • What resources and executive summary reporting are in place to oversee your payer contracting and payer engagement program?
  • When were your payer contracts last re-negotiated?  How often do you meet with your top payers?
  • Is your payer contracting strategy aligned with your five year strategic scaling roadmap?
  • Does your annual budget and strategic review include key next 12-month payer contracting goals?
  • Is the cost and quality value proposition originally pitched to payers clearly represented in your day-to-day operational reality and periodic reporting back to payers?
  • How are you overseeing maintenance of existing contracts?
  • Do you monitor service line profitability?
  • Are payer terms hardwired into your EHR?
  • What resources and reporting are in place to oversee provider credentialing, as well as troubleshoot payer-related claim adjudication issues?

How We Work

STEP 1: Deeply understand the genesis and status of current contracts.

What’s working and what’s not? Where do value add opportunities exist based on current state?

STEP 2: Develop a value proposition based on strengths of the group.

Develop a value proposition based on strengths of the group, five-year practice strategic roadmap needs and opportunities, current levels of payer engagement, and potential value offered to payers & broader market stakeholders.

STEP 3: Agree on strategy and timetable.

Agree on strategy and timetable, including desired terms and target strategic partnerships, as well as your provider capacity, resources, strengths, tools and workflows. Prioritize contract processes by identifying which initiatives drive the most value.

STEP 4: Execute on payer contracting roadmap.

Execute on payer contracting roadmap; implementing appropriate executive summary reporting for on-going status transparency.

STEP 5: Monitor results and performance.

Continue on-going payer engagement: demonstrate that results achieved align with originally communicated targets goals; identify the next round of value add target initiatives to achieve evolving practice and payer objectives.

Case Study

Challenge

Our Client was out-of-network with several key payors with no strategy for moving in network. The Client’s payor contracting resource was new to the organization and the Client’s executive leadership and private equity Board wanted extra oversight of the process.

Action

The Scale Physician Group payer contracting team oversaw the Client’s payer contracting team through weekly update calls. We worked with the Client to formalize priorities as well as executive summary reporting to cleanly and clearly track performance across priority contracts and key process milestones. We developed transparency of process status, accountability for the payer contracting team, and efficient prioritization of the task at hand.

OUR TEAM

Payer Contracting Experts

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