Article | March 22, 2022

Managed Care Contracting: Negotiating Physician Reimbursement Contracts with Third Party Payers

The Concern

Being responsible for the financial success of a physician practice is vastly different than having financial responsibility for a hospital. The financial success of a physician practice involves physician productivity, coding, credentialing, contract execution and efficacy. Having a working knowledge of these complex issues can be overwhelming for the hospital CFO.

Externally, there is growing concern by the OIG of losses associated with hospitals employing physicians. A financially sound third party payer contract is dependent on a thorough understanding of the current managed care market and an awareness of the “silent” terms in the contract that can affect profitability.

Internal operational concerns include understanding the physician billing complexities, which vary based on specialty and location of service. This includes specific coding issues related to compliance and reaching revenue potential as well as credentialing issues. Provider based issues need to be understood and handled appropriately.

Hospital executives must ask themselves the following questions: Do we have enough knowledge and information to effectively negotiate third party payer contracts? Do we know the “what” and “why” of maximizing Part B revenue? Do we have qualified staff to carry out the contracting functions or should we outsource managed care contracting functions?

KOHLER HealthCare Consulting can help you by:

  •  reviewing your existing managed care contracts
  •  evaluating the managed care market in your service area
  • creating an understanding of how CPT/HCPCS codes work; what is required by Medicare and other payers; and establishing how the physician reimbursement system differs from the hospital model
  • providing an analytical tool to evaluate third party payer fee schedules
  • identifying and minimizing the issues and daily hurdles
  • providing the necessary training for your staff
  • establishing internal mechanisms to report and control payer problems
  • providing ongoing support for third party payer issues