Knowing all of the benefits of Payer Planning, National Specialists* located in the Midwest, United States, a multiple-provider single specialty physician practice serving a metropolitan Midwest city, recognized that there were improvements to be made and set out to implement a revised strategy. They began an initiative to identify and benchmark payer performance and financial variables.

*National Specialists is a pseudonym used to protect the client’s name and identity for this case study.

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THE CHALLENGE

Implementing a Payer Planning Strategy is a critical step in improving overall practice financial performance outcomes, both in terms of monitoring existing contract language and reimbursement conditions, and revised or payer invoked changes to existing agreements. Practices that implement and maintain a perennial approach to managing payer relations can enhance timely and accurate claims payment and payer contract adherence while developing expanded payer relationships. From a financial standpoint, proactive assessment of the practices’ payer landscape is a relatively low-cost/high-yield method of improving margin, both directly from visit volume reimbursement and through downstream enhancement of overall payer planning compliance.

The Solution

Engaging Dean Dorton healthcare advisors and enterprise analytics, the practice worked in partnership to establish essential “building blocks” related to payer contract language, distinguish a pre-negotiation payer assessment, outline payer performance analysis, benchmark financial parameters, and implement reformation of process management. Determined to understand and validate relevant practice deliverables in areas of demonstrated quality of care, access, and shared accountability in partnering with payers to manage cost of care and cost trend, the practice positioned themselves to engage in revised strategy specific to Payer Planning implementation.

Results

Initial results were promising. Within a three-month timeframe of the initiative, the following occurred:

  • 60% of the eligible payer contracts assessed and revised to achieve the language and rate objectives of the practice
  • Rebalancing and revision of reimbursement rates, per CPT/HCPCS code
  • Recovery of Errant Payer Expected Payment
  • Charge Master Reform
Greater than 20 percent

increase in annual reimbursement, recovery of errant payment, and enhanced contracts

Why Dean dorton

In addition to the above outcomes, areas of existing underpayment discovered led to the substantial reconsideration of claims processing. Of note, the assessment further yielded needed revision in the overall charge structure delivery of the practice, which, if left unmanaged, contributed to long-term compounding reduction in payment compliance. The physician practice leveraged Dean Dorton healthcare advisors’ expertise and enterprise analytics to successfully monitor and meaninbfully impact the financial future of their practice.