Comparative 8/25

MedicareEnroll8/26

MedHome 10/28

Hospitals and managed care organizations (MCOs) are taking a more collaborative approach to ensure that their negotiated terms produce the financial results that they expect. In the recent past, hospital and MCO agreements have included significant changes in payment methodologies as the parties move toward episode based reimbursement terms. In order to successfully negotiate a new agreement, both parties must understand the impact of the proposed financial terms. This typically involves applying the proposed contract payment methodology and terms to historic claims data and comparing the projected payments to the current reimbursement. While the concept is simple in nature, in practice the complexities of hospital billing result in significant differences between data sets used by the health plan and the hospital.

Failure to appreciate the intricacies and subtle differences between the data sets can result in unintentional but material misrepresentations of the financial impacts of a proposed agreement. When these problems are uncovered, they complicate negotiations by inserting a measure of mistrust. Recognizing these risks and planning for appropriate data reconciliation thus becomes an important part of negotiating agreements between MCOs and hospitals.
         

• The critical elements of modeling a hospital agreement including often overlooked variables such as:
  • "Lesser of payment or charges" language.
  • Annual charge master increases or other inflators.
  • Case rate thresholds.
  • Short stay clauses.
  • Service bundling rules.
• Common issues that can misstate charges or modeled reimbursement:
  • Denied charges included in the model.
  • Patient registration errors.
  • Interim billings that understate charges.
  • Improper application of short stays or similar clauses.
  • Incorrect treatment of charges or payments for babies in maternity cases.
• Case Study
  An actual negotiation between a large Midwest hospital and MCO will be reviewed. In this situation, the MCO proposed a new agreement that significantly changed payment methodologies. The data used by the MCO in its initial modeling resulted in a material misstatement of the contract performance. The hospital was able to perform a reconciliation that resulted in a mutually acceptable data set that both parties agreed resulted in a reasonable projection of contract performance.

• Hospital executives and managers responsible for negotiating MCO agreements
  • CEO
  • CFO
  • Managed Care Vice Presidents or Directors
  • Contract Administrators
• Health Plan executives and managers responsible for negotiating hospital agreements.
  • Network Managers, Directors, Vice Presidents
  • Provider Representatives
    

Ms. Welter, Principal, works in ECG Management Consultants, Inc.'s Healthcare practice. Her experience in reimbursement and strategy gives her the skills necessary to address the issues facing today's healthcare leaders. 

Summary of Expertise
Ms. Welter has extensive experience in the area of managed care, including strategy development, reimbursement, contract negotiations, and operations. She has assisted several hospitals and medical groups in the financial planning and turnaround of their managed care contracts. 

She has also managed multiple engagements to provide strategic and financial planning advice to hospital and medical group senior management. As part of this work, Ms. Welter has developed and analyzed complex market studies involving patient origin analyses, market share assessments, physician supply and demand studies, and medical staff resource planning. 

Affiliations
Ms. Welter serves as a board officer and the managed care committee chairperson for the Healthcare Financial Manage-ment Association's (HFMA's) Washington Metropolitan Chapter. 

Education
She holds a master of healthcare administration degree from Villanova University and a bachelor of arts degree in preprofes-sional studies from the University of Notre Dame.

Speeches and Articles
Ms. Welter has been the featured speaker on managed care and provider reimbursement for a variety of national profes-sional associations, including HFMA and the Medical Group Management Association (MGMA). She has also been published in several healthcare journals.

Mr. Brown, Senior Manager, works in ECG Management Consultants, Inc.'s Managed Care practice, where he focuses on strategic health plan contracting, negotiation, and revenue recovery. 

With more than 18 years of healthcare management and consulting experience, he has been successful in improving the bottom line of clients' financial and operational performance.

Summary of Expertise
Prior to joining ECG, Mr. Brown served as a Director at CHC Healthcare Solutions, a subsidiary of Computer Horizons Corp. (now TEKsystems Inc.), lending his deep knowledge of managed care operations to assist clients in complying with the intricacies of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and Sarbanes-Oxley §404 requirements. Mr. Brown also served as a Director at a national consulting firm, where he focused on managed care contracting, operations, and revenue recovery. In addition, he was Director of Managed Care/Vice President of Practice Operations at Founders Health Care (Allegheny Integrated Health Group), and Operations Manager/Medical Center Administrator at FHP Inc.

Affiliations
- Colorado Healthcare Strategy and Management.
- Healthcare Financial Management Association (HFMA).

Education
Mr. Brown holds a master of business administration degree from the University of Utah and a bachelor of arts in biology from the University of Colorado.
 

Corporate Site licensing also available. Click here to register or call 209.577.4888 We look forward to your participation in this event!