Payer Relations and Contracting

Payer Relations & Contracting

THS will ensure readiness, accurate understanding of financial implications, and ultimately the success of each contracting model in diverse market segments (Commercial vs. BPCI/CJR vs. Medicare Advantage). THS will educate both the administrative team and providers about these different models and the financial impact to support the operational changes that must take place for ongoing revenue growth at the group, with an outpatient joint program being the initial strategic project.

Service Description
Basic Education across all topics Gone are the days we can engage payers in discussions on FFS rate increases, here are the days that payers want to discuss decreases and movement to value-based care models. Ensuring readiness, accurately understanding financial implications and ultimately ensuring success is based on each model as well as different market segments (Commercial vs. BPCI/CJR vs. Medicare Advantage). THS will educate both the administration team and providers about these different models and their financial impact to support the operation changes that must take place for ongoing revenue growth at the group.
FFS Contracting & including Analysis There are opportunities to defend current revenue and optimize future revenue growth by re-allocating rate across specific procedure categories and codes. Payers are increasingly accepting steerage and volume commitments to obtain rate decreases in target areas (example MRI) that may serve to enhance revenue growth for the group. THS will work within each provider group to understand the market dynamics to develop and execute a specific contracting strategy as well as perform contract rate analysis to understand the overall impact of rate schedules to the group's finances.
Site of Service Negotiation & Management Incentives are tied to specific performance and may have claw back provisions should expected transition not occur. THS will work within each provider group to develop and execute a specific site of service contracting strategy across all locations (hospital, ASC, provider's officeand perform the analysis to communicate the savings to the payer and the process to monitor adherence. THS will also provide tools to ensure that the information provider's need to make the decision gets to them in time to impact change.
Value-based Contracting THS will engage all payers in value-based contracting efforts and manage the process of analyzing the different value-based care models to determine the specific financial impact and then creating the operational changes necessary to ensure optimization of results.
Shared Savings Analysis (w/Payer Data) Each payer agreement will follow business and clinical rules to estimate the shared savings potential and to design operations. THS will develop a payer-specific analysis that details the financial impact of the program design and translate that to a per provider expectation. THS will then lead the process to educate the providers on their performance and design the operational changes to maximize performance under the program. THS will manage the process of analyzing the different models to determine the specific financial impact and then creating the operational changes necessary to ensure optimization of results.
Prospective Bundle Analysis (w/Payer Data) The group will have to develop not only a case rate for the payer, but set up the correct sub-contractor relationships with the facility and all related other providers (ex: anesthesiology, radiology, hospitalist, etc. The financial analysis to develop a prospective bundled rate must take into account the expected facility mix. Finally, often the group must engage in risk management tactics (such as negotiating outliers or seeking reinsurance). THS will manage the process to develop correct pricing, provider relationships and risk management tactics to ensure success under a prospective payment model.
FFS Revenue Optimization THS will analyze and manage all aspects of the FFS contract negotiation process. This includes rate modeling to ensure understanding of the impact of contract modifications, optimization of rate and volume to deliver the revenue and profit goals and retrospective analysis of the agreement to ensure results. THS leverages industry tools and data sets in this process to ensure competitiveness in the market.
Provider Credentialing Services All commercial and government payer agreements have enrollment and credentialing requirements that must be met to ensure that providers are qualified to participate in their products. Under full MSO services, THS will assume management of this ongoing process which include provider enrollment, maintaining and monitoring all required medical licenses, hospital privileges to include initial appointment and reappointment, maintain and update CAQH profiles, status research, and monitoring NPI records and registration. Our team works with great efficiency and a full understanding of the credentialing process.
 


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