Payor Contract Analytics and Negotiations

Payor Contract Analytics & Negotiations

2 men review contracts

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All too often Payors have more control when it comes to contract negotiations and discussions can become contentious. MedCom helps drive data-driven negotiations with Payors through a technology based methodical approach. We evaluate key operational processes that impact Payor Contract Management with Payor Contract Analysis, Charge Master/Pricing Assessment, Implant Charge Capture, and 837/835 Payment Analysis.

Don't let Payors dictate what you are paid. Our experts ensure you are paid what you are entitled to!

Payor Contract Analysis

MedCom reviews current payor contract terms for major commercial and managed Medicare/Medicaid payors to identify the current level of reimbursement, as well as highlight potential opportunities for contract renegotiation to enhance net revenue.

  • Using contract documents and 835 payment files, we:

    • Measure gross and net revenue associated with each payor and plan type.
    • Create reimbursement indices using Medicare benchmark.
    • Identify service areas with large contractual adjustments or zero payment.
    • Review payor “pain points” – such as line-item denials for specific services.
    • Identify charges potentially hitting “lesser of” clauses or below fee schedule amounts.
    • Assess critical contract terms (e.g. timely filing limits, carve-outs, exclusions).
    • Highlight instances in which the payor is not paying according to current contract terms/rates.
    • Propose future rates and terms for each payor and plan type, including financial impacts.

Payor Contract Negotiations

Once payor contracts and 835 data have been analyzed, MedCom provides a plan for renegotiation of payor contracts. The plan will include strategies and payment levels for various contract rates and terms that ensure net revenue improvement where appropriate. MedCom produces a contract negotiation playbook to support client’s internal team with renegotiations, and our consultants can take a lead role in conducting payor contract negotiations at the client’s request.

  • Payor Negotiation Playbook

    • Summarize all findings and recommendations for each payor and plan type.
    • Index payment rates against Medicare to highlight appropriate benchmark for negotiation.
    • Identify negotiation strategies for appropriate carve-outs under various fixed-payment models.
    • Prepare a market report summarizing reimbursement rates of local and regional market competitors utilizing publicly available price transparency data.
    • Estimate financial impact for proposed rates at various levels to support renegotiation.

  • Consultant Negotiation Service

    MedCom consultants can assist with negotiations or act on behalf of the client as contract negotiators with third-party payor representatives. In consultation with client senior leadership, MedCom will communicate desired rate increases and language updates to third-party payors and work through renegotiation of each area. As MedCom and client renegotiate various services, MedCom will provide financial impact estimates to client senior leadership to facilitate decision-making processes with each payor. Once the contract renegotiation process is complete, MedCom will provide a full financial impact summary.

Experts at the Negotiations Table

At MedCom, we understand that many providers just don't have the time or resources to perform the necessary analyses for successful discussions and negotiations. With the support of the MedCom team, you can maximize your organization's efficiency and take control of your charge systems and processes. Let us be your experts at the table so you can focus on patient care!

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