Provider contract management is a big topic that could have volumes written about it. Every healthcare payer struggles with many of the same challenges.
- Lack of centralized and organized contract repository
- Disconnects between “paper” contracts and system-configured contracts
- Confusion regarding which tax IDs are covered under which contracts
- Difficulty managing provider movement in and out of network
- No ability to quickly find all contracts with certain terms (e.g., all contracts that have AWP or SNF pricing)
A good payer contract management system can help to address many of these issues. Here are some things you should do when implementing such a system.
Establish Clear Provider Contract Management Policies
The first step is not a “systems-related” step at all. Your contract management policies should define how you handle provider contracts. Without clear policies, any system implementation is likely to be messy and costly. You will lose out on much of the benefit. You could leave users and leadership wondering why you needed a system to begin with.
Your policies should include processes for ensuring that you have machine-readable soft copies. If you use a contracting system that enables fully digital contract negotiation and execution, you should ensure that it allows for deep integration with other platforms. This includes claims and provider data management systems.
Your provider contract management processes should also include capturing structured information about your contracts. This should include:
- All tax IDs associated with the contracts, along with W-9s and accurate pay-to names and addresses
- The scope of services defined within the contract
- The types of providers covered by the contract (e.g., Physicians, Inpatient, Outpatient, SNFs, ASCs, Home Health, Hospice, etc.)
- The basic terms of the contract including the basis for the fee schedule (Medicare, Medicaid, Custom, etc.) and the percentage of the basis that you must pay
- Details about specific pricing methodologies to be used (e.g., IPPS, OPPS, ASP or AWP, EAPG, etc.)
- Any custom rates established, such as per hour rates for home health visits and per diem rates for residential facilities
Connect Your Claims System & Soft Copy Contracts
Within your claims system, you will have a “contract” that is a set of terms used to calculate and pay a claim. Many payers lack the ability to connect what is configured in the claims system with what is in the written contract.
This can lead to difficulties in auditing claims payments, finding inaccuracies, and responding to provider appeals and complaints. Your payer contract management system should allow you to connect the soft copy contract to the specific contract name and identifier within your claims system.
Your claims system will define contracts generically. It is not generally a one-to-one mapping from a provider to a contract. Instead, you will have a “100% of Medicare PAR” contract. This may cover most of your physician agreements. It is important to be able to connect the provider’s actual contract with the contract structure used to pay them.
Once you’re able to do this, auditing becomes a much simpler task. In fact, it can often be automated. This allows your team to focus on expanding your network and improving access for members.
Audit Your Provider Contract Configuration
Once you have addressed the first two steps, you can begin to audit your contract management. This might include:
- Ensuring that every provider or vendor has a soft copy contract associated
- All soft copy contracts are associated to a configured contract
- Configured contracts match what is in the written agreement
- You have providers mapped to the right contracts
You should aim to automate the audit so that it can be reviewed each month. That gives you the opportunity to address the gaps before they cause problems for your network.
Provider Contract Management with Maven One
With the Maven One payer contract management system, you can automate contract auditing. This saves your team time while also giving you deep insight into where your gaps are. Our rules engine connects seamlessly with our provider workflow engine. This gives you the ability to identify issues and automatically initiate action to correct them. Request a customized demo today to see how it can help you improve your processes.