Review of Key Managed Care Processes
Consulting Services | Revenue Cycle | Revenue Cycle Solutions | Managed Care Services | Review of Key Managed Care ProcessesA good agreement is only the starting point
A good managed care agreement is a good start, but even the best agreements require follow-up: processes to ensure that your payors remain in compliance with the terms of their contracts.
Here’s how QHR can help.
Financial integrity through monitoring.
QHR’s managed care specialists can show you how to monitor the performance of each agreement for compliance. We address payment consistency, inappropriate denial activity, retrospective recoupment by payors, and more. We’ll help you put the proper processes in place to guarantee compliance and protect the financial integrity of your agreements.
- We conduct on-site audits of payment verification processes to ensure that PFS staff validate all payments, the organization has appropriate logging and reporting processes in place to capture incorrect payments, and PFS staff are performing proper follow-up collection activities.
- Our experts evaluate your hospital’s denial management processes to validate that denials are reported and addressed to overturn where appropriate, and that summary information is captured to assist management in evaluating the performance of the various managed care agreements.
- QHR conducts a review of the content and availability of performance reports of all agreements to determine if sufficient information is available to evaluate the performance of each agreement. Next steps are identified to address problem payors via dispute resolution processes or later at contract renegotiation. We offer sample reports and formats for implementation.
- Where practical and economically feasible, we develop recommendations to automate payment verification and denial management processes.
- We provide specific examples of tools to be used by PFS staff to streamline the claims payment validation process (including payment variance logs, top payor reports, contract matrices that include all payment terms, etc.
The revenue is in the details.
QHR can help you take the next step after negotiating good contracts. Make sure you’re securing all appropriate reimbursement, by monitoring your managed care payors’ compliance with contract terms.
