Strategic Payor Contracting
Despite its critical role in driving on-going performance and facilitating strategic scaling, payor contracting is commonly one of the more opaque departments within the physician platform ecosystem. As practices scale and payor 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 payor contracting requires a precise approach: invest in qualified oversight and transparent performance reporting as well as clearly, realistically, and proactively defined strategies.
- What resources and executive summary reporting are in place to oversee your payor contracting and payor engagement program?
- When were your payor contracts last re-negotiated? How often do you meet with your top payors?
- Is your payor contracting strategy aligned with your five year strategic scaling roadmap?
- Does your annual budget and strategic review include key next 12-month payor contracting goals?
- Is the cost and quality value proposition originally pitched to payors clearly represented in your day-to-day operational reality and periodic reporting back to payors?
- How are you overseeing maintenance of existing contracts?
- Do you monitor service line profitability?
- Are payor terms hardwired into your EHR?
- What resources and reporting are in place to oversee provider credentialing, as well as troubleshoot payor-related claim adjudication issues?
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 payor engagement, and potential value offered to payors & 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 payor contracting roadmap.
Execute on payor contracting roadmap; implementing appropriate executive summary reporting for on-going status transparency.
STEP 5: Monitor results and performance.
Continue on-going payor 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 payor objectives.
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.
The Scale Physician Group payor contracting team oversaw the Client’s payor 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 payor contracting team, and efficient prioritization of the task at hand.
Robert Dondes, Chief Advisor of Managed Care & Payor 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.
Mike Mirt, Chief Advisor of Executive Payor 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.
Mike Reed, Chief Advisor of Primary Care, Medicare Advantage, ER Staffing, and Hospital-Based Physician Services
Mike brings more than 35 years of experience in health care leadership, having served roles as a hospital administrator, as well as a physician practice, population management market, healthcare M&A and healthcare business development executive. Mike recently served as Head of Strategy and Business Development at The Oncology Institute.
Suniti Ponkshe, Chief Advisor of Payor 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.