Managed Care - February 2009 - (Page 37) Payers are rapidly implementing quality measures, yet providers may not trust that the plans will compensate them fairly, accurately, and quickly. Without that trust, physician compliance suffers, so payers must be able to demonstrate that they know what should be paid and how it must be paid. The solution is for payers and providers to agree on what data should be shared and how. They must also come to agreement on what outcome goals should be achieved, on the clinical processes to get there, and on how outcomes will be measured. ments must be met to obtain payment, and how much will be paid. Specificity, clarity, and good faith ultimately will reduce the risks in network management. Ever-changing code definitions, date sensitivities, and regulatory needs inevitably present a challenge. We have all seen the underpayment or overpayment that results when the multiple parties involved on the payer side and their counterparts on the provider side reach different interpretations of the same matter. The goal should be systems that A good contract yields first-pass auto-adjudication rates of at least 80 percent. The consequences of ambiguity are costly. Most of all, the payers and providers should decide together that if certain goals are achieved — financial, outcome-, or quality-related — then, using a clear formula, both parties share in the economic benefit. Accurate measurements and payment are the starting points for trust. How is accuracy defined? It all goes back to the contract. The contract is the root of all success and is central to any network management improvement strategy. It can perpetuate the mistrust that has developed between payers and providers, or it can break that cycle. A strategic organization will learn to use the contract as an instrument of collaboration between payers and providers. The highest priority in a network management strategy should be contracts that make payment timely, transparent, and seamless. Too often, it takes nine months to negotiate a twelve-month contract. The most time-consuming aspect of the negotiation involves reconciling what the payment system did or did not pay correctly. Where providers perceive underpayment, which can feed the cycle of mistrust, the reason could merely be an outdated system that just doesn’t work well, or it could be that new contracts have not been loaded into the health plan claim system in a timely manner. breed consistent interpretations without human intervention — ideally with all details clearly spelled out and communicated to providers. Contracts should be complete and self-evident. A good contract yields first-pass auto-adjudication rates of at least 80 percent. The consequences of ambiguity are costly. With the extra manpower and time involved, each subsequent pass on a claim can cost an organization as much as $25 per claim and sometimes more. Watchword Transparency has become a watchword in our industry, but it truly applies to contracts. In a collaborative environment, the contract must make clear what services will be paid for, what require- Automate and reap Technology makes a collaborative relationship between a plan and its providers possible. Automating the contracting process can help an organization reach key goals. For example, it can shorten contract negotiation time. Automation enables a plan to make changes quickly and efficiently without introducing errors, and then to communicate changes throughout an organization. Plans can thereby cut the risks and costs that occur when unique contract information must be entered manually into a claims processing system, where a single mistake can result in the need to reprocess many claims. Plans that have retooled their network management processes to make them more strategic, automated, and collaborative have reported an increase in auto-adjudication rates and the accuracy of claims paid, and a decrease in provider relations appeals. Automation also helps plans comply with government requirements to notify providers of changes. This often is done manually now, with enormous costs for printing, postage, and return re- FEBRUARY 2009 / MANAGED CARE 37
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