They should look at the impact the payer will have on their workflow such as

They should look at the impact the payer will have on

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not be the rate of compensation. “They should look at the impact the payer will have on their workflow, such as responsiveness to problems with claims, products they offer, and implementation of new policies and procedures” (Vega, 2013). Since MHG is an integrated healthcare organization with many different care delivery systems, they need to consider an agreement for the whole organization instead of just the hospital itself. A comprehensive payer profile should be created before MHG sits down to negotiate the contract (Vega, 2013). There are a few different ways a payer profile can be completed, MHG can reach out to the third-party payer, review claims history, analyze denials, and ask the revenue cycle personnel about issues with the payer. "The payor profile offers insight on what the payer hopes to gain and what they bring to the table" (Vega, 2013). Lastly, MHG needs to have an open mind when negotiating. Having an open mind allows them to make compromises and reach an agreement with the payer on the managed care contract. Communicate “Managed care organizations manage the care that is provided to their members to ensure that the appropriate level of care is provided and that the access to the most expensive levels of care are controlled and delivered as medically appropriate” (Harrington, 2016). The provider will coordinate the care to the managed care organization members. The provider controls what tests, treatments, and specialists the patient utilizes. Utilization management personnel “is responsible for the day-to-day provisions of the hospital’s utilization plan” (Harrington, 2016). The Case Manager finds providers in the patient’s network that fits their needs. “Prescription Benefit Managers manage the prescription portion” (Harrington, 2016). Case Managers manage the accessibility of care for the patient. Health care providers and organizations, patients, and third- party payers all share financial risk and control with a managed care contract. Making sure that
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WHITE PAPER 21 the managed care contract is successfully negotiated and managed all MHG to maintain revenue, a chance at increasing revenue, bring in new patients and improve patient satisfaction. Contracts As discussed earlier, managed care contracts help to increase the quality of care provided and reduces the cost of healthcare. The impact a new managed care contract has on reimbursement depends on the negotiation. A new managed care contract helps to sustain reimbursement from managed care organizations and could allow MHG to gain additional reimbursement. Many different payment methods are used in managed care contracts. One is the bundled payment, “involves making a lump sum payment to cover all services that were delivered to a patient for a specific illness that was tread during a specific period” (Harrington, 2016). A capitation payment will be negotiated to agree on a contract that will cover listed services for a population at a set monthly fee per member (Harrington, 2016). Global payment is
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