Managed Care & Reimbursement Frequently Asked Questions
Which contract provisions should be understood before payer negotiations begin?
PYA identifies the agreement term and termination clauses, payer payment obligations, payer policies, arbitration provisions, covered services, the providers and payers subject to the agreement, site-of-service considerations, and the economic terms by service as important parts of a current-state contract review.
How can financial modeling improve managed care contract decisions?
Rate analysis and contract modeling can be used to compare reimbursement, test proposed terms, and evaluate how different contract scenarios may affect expected payment. PYA also uses closed claims and other financial data to examine payer performance, reimbursement variation, and the relationship between rates and service volume.
How can price transparency data support managed care strategy?
PYA uses price transparency data to compare negotiated rates among peer health systems, facilities, and payers. Combined with market benchmarking and financial modeling, the data can highlight rate variation, inform negotiation planning, and provide additional context for evaluating contract performance.
What can managed care dashboards reveal to leadership?
PYA’s dashboards and reporting tools are designed to provide visibility into reimbursement trends and performance. They can also support payer scorecards that track reimbursement rates, service volume, contract performance, denials, underpayments, and areas that may warrant further review or negotiation.
Which reimbursement areas should be reviewed beyond commercial payer contracts?
PYA’s services also address Medicare and Medicaid cost reports, DSH, bad debt and S-10, wage index, settlement estimates, strategic reimbursement assessments, 340B, revenue cycle processes, documentation and coding, fee schedules, denials and appeals, and key performance indicator tracking.
