02 — Capability · BC-1840.60
Payer Contracting
Negotiate payer contracts that pay fairly for the care delivered, model their effect before signing and load the terms so every claim can be checked against them. A health plan contracting with its provider network is health plan operations.
- Managed Care Contracting
- Payer Relations
- Reimbursement Contracting
In scope
- Contract negotiation and renewal with commercial and government plans
- Reimbursement modeling of proposed terms and the government cost report
- Loading contract terms for expected payment
- Enrolling clinicians with each payer, and escalating payer issues
Out of scope
- Value-based and risk-sharing contract performance (see BC-1860.30)
- Health plan provider network contracting (see BC-1870.30)
- Contract repository and lifecycle in general (see BC-640.20)
Realized by · 1
- Oracle Health · Contract Managementstrong via BC-1840.60.20
Used in · 0
- Not yet placed on a value stream.
Build it · 0
- Nothing in the library points here yet.
Decomposes into · 6
- BC-1840.60.10Payer Contract NegotiationPrepare for and negotiate rates, terms and renewals with each payer, from a clear view of cost, volume and market position.
- BC-1840.60.20Reimbursement ModelingModel what a proposed contract or rate change would pay on the organization's own claim history before it is signed.
- BC-1840.60.30Contract Terms LoadingLoad each signed contract's payment terms into the systems that calculate expected payment, and test them against real claims.
- BC-1840.60.40Payer Relationship OperationsRun regular operating meetings with each payer, escalate systemic payment issues and track policy changes that affect payment.
- BC-1840.60.50Clinician Payer EnrollmentEnroll each clinician and location with every payer the organization contracts with, and keep those records current, so claims for their services are accepted and paid.
- BC-1840.60.60Cost Report & Government ReimbursementPrepare the annual cost report and the government reimbursement filings and settlements that follow from it, and model their effect on payment.