Strategic Payer Contracting

Overview

Despite its critical role in driving on-going performance and facilitating strategic scaling, payer contracting is commonly one of the more opaque departments within the physician platform ecosystem. As practices scale and payer contracting becomes an increasingly overwhelming task, practices frequently submit to unclear performance reporting and ambiguously defined goals.

However, given its importance and technical nature, we believe payer contracting requires a precise approach: invest in qualified oversight and transparent performance reporting as well as clearly, realistically, and proactively defined strategies.

Assess Your Payer Contracting Program

  • What resources and executive summary reporting are in place to oversee your payer contracting and payer engagement program?
  • When were your payer contracts last re-negotiated?  How often do you meet with your top payers?
  • Is your payer contracting strategy aligned with your five year strategic scaling roadmap?
  • Does your annual budget and strategic review include key next 12-month payer contracting goals?
  • Is the cost and quality value proposition originally pitched to payers clearly represented in your day-to-day operational reality and periodic reporting back to payers?
  • How are you overseeing maintenance of existing contracts?
  • Do you monitor service line profitability?
  • Are payer terms hardwired into your EHR?
  • What resources and reporting are in place to oversee provider credentialing, as well as troubleshoot payer-related claim adjudication issues?

Our Process

STEP 1: Deeply understand the genesis and status of current contracts.

What’s working and what’s not? Where do value add opportunities exist based on current state?

STEP 2: Develop a value proposition based on strengths of the group.

Develop a value proposition based on strengths of the group, five-year practice strategic roadmap needs and opportunities, current levels of payer engagement, and potential value offered to payers & broader market stakeholders.

STEP 3: Agree on strategy and timetable.

Agree on strategy and timetable, including desired terms and target strategic partnerships, as well as your provider capacity, resources, strengths, tools and workflows. Prioritize contract processes by identifying which initiatives drive the most value.

STEP 4: Execute on payer contracting roadmap.

Execute on payer contracting roadmap; implementing appropriate executive summary reporting for on-going status transparency.

STEP 5: Monitor results and performance.

Continue on-going payer engagement: demonstrate that results achieved align with originally communicated targets goals; identify the next round of value add target initiatives to achieve evolving practice and payer objectives.

Case Study

Challenge

Our Client was out-of-network with several key payors with no strategy for moving in network. The Client’s payor contracting resource was new to the organization and the Client’s executive leadership and private equity Board wanted extra oversight of the process.

Action

The Scale Physician Group payer contracting team oversaw the Client’s payer contracting team through weekly update calls. We worked with the Client to formalize priorities as well as executive summary reporting to cleanly and clearly track performance across priority contracts and key process milestones. We developed transparency of process status, accountability for the payer contracting team, and efficient prioritization of the task at hand.

Our Team

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Tracy Bahl, Chief Advisor of National Payer Strategy

Tracy brings over 20 years of senior leadership experience in the healthcare industry to SCALE.  Most recently, he was the President & CEO of OneOncology, a partnership of independent community oncology practices with over 242 oncology providers and 134 care sites across the country.

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Gail Coffman, Chief Advisor of Payor Contracting

Gail brings 35 years of clinical and healthcare administration experience to SCALE. Most recently, Gail was the Manager of Third Party Vendor Management for Cigna Healthcare where she was responsible for contracting and operations for 20 full-service medical networks nationwide.

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Robert Dondes, Chief Advisor of Managed Care & Provider Networks

Bob was the founder and president of Concert LLC, a wholly-owned subsidiary of the University of Pittsburgh Medical Center (UMPC).  Concert is a clinically integrated network (CIN) built around value-based reimbursement and population health quality measures.

Bob’s previous tenure included 20 plus years as a managed care and health insurance c-suite executive.  He served as the CEO of a Pennsylvania-based third party administrator (TPA) as well as a captive preferred provider organization (PPO).

Bob has held several c-suite positions over the course of his career for a range of healthcare companies.

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Joseph (Joe) Keane, Chief Advisor of Managed Care Contracting

Joe has more than 20 successful years of creating value in several key C-Suite roles in the healthcare industry.  Joe’s experience ranges from building, scaling, and operating PE backed growth companies to restructuring distressed companies by serving in several Chief Restructuring Officer roles.   He has in depth experience in the Dental Service Organization (DSO) sector as well as other “Provider-side” healthcare management sectors including hospital, institutional pharmacy, long-term care, orthodontics, and vision.

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Premise Health Mike Mirt

Mike Mirt, Chief Advisor of Executive Payer Strategy & Corporate Health Clinics

Mike brings more than 40 years of leadership experience in the healthcare industry. Recently, Mike was Executive Chairman of Premise Health. Previously, he was President of HealthSpring, one of the largest Medicare Advantage plans in the United States.  The company was acquired by Cigna Corporation.  Prior to that, Mike was Executive Vice President and Chief Operating Officer of AmeriChoice, a UnitedHealth Group company offering healthcare coverage to Medicaid beneficiaries.  He is also the former regional President of Cigna Healthcare.

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Suniti Ponkshe scale physician group

Suniti Ponkshe, Chief Advisor of Payer Contracting Analytics

Suniti is a Partner at the Newport Board Group, a multidisciplinary expert network advisory services firm.  Previously, Suniti served as Anthem’s Staff Vice President of Product Innovations and Development focused on optimizing CareMore’s care delivery model. She also worked with several health systems across the country in Medicaid transformation initiatives such as DSRIP, value based payments and others.

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