Review of Key Managed Care Processes
While a good agreement is the right starting point, the performance of each agreement must be
monitored for compliance relative to payment consistency, inappropriate denial activity, retrospective
recoupment by payors, etc. Managed Care can assist the hospital by insuring the proper processes are
in place to guarantee such compliance.
■ On site audits of payment verification processes can be
conducted with the intent of insuring that PFS staff validate
all payments, appropriate logging and reporting processes
are in place to capture incorrect payments, and associated
follow up collection activities of PFS personnel occur.
■ Audits of denial management processes are conducted
to validate that denials are reported, followed up to overturn
where appropriate, and summary information is captured to
assist management in the evaluation of the performance of
the various managed care agreements.
■ A review of the content and availability of performance
reports of all agreements is conducted to determine if
sufficient information is available to evaluate the
performance of each agreement, and next steps are
identified that are necessary to address problem payors
via dispute resolution processes, or later at contract
renegotiation. If such reports are not available,
recommended sample reports and formats are provided
to the hospital for implementation. | ■ Where practical and economically feasible,
recommendations are developed to automate the
payment verification processes and denial
management processes.
■ Specific examples of tools to be used by PFS
staff are provided to streamline the claims payment
validation process- including sample payment variance
logs, top payor reports, contract matrices which include
all payment terms, etc. These tools can make the job
more efficient for the claims payment verifier. |
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