Along with CMS’s commitment to expand pay-for-performance programs and alternative payment models, commercial plans are now expanding their risk-based contracting. However, many provider organizations do not fully appreciate the challenges and benefits of these arrangements—nor have they developed and deployed strategic and tactical plans for success under risk-based contracts.

PYA’s diverse team of experts (operations, data analytics, managed care contracting, coding, strategy, regulatory, and revenue cycle) has the experience to meet your organization’s risk-based contracting needs. Our four-phase data-driven approach is tailored to your specific market.

Phase 1: Assessment

Conduct a thorough gap analysis and prepare a specific action plan

  • Has the leadership team assessed its readiness for risk-based contracting?
  • Do all entity stakeholders fully understand riskbased contracting?
  • Has the operational infrastructure been established?
  • Has the provider entity invested in data management to monitor key metrics?

Phase 2: Market Analysis

Conduct an external market analysis

  • Determine the provider entity service area.
  • Determine the payer market share by payer class.
  • Determine provider entity patients by payer class.

Phase 3: Contract Negotiations

Prepare for and engage in contract negotiations

  • Determine level of risk the provider entity is willing and able to assume.
  • Determine attributed membership for the patient population identified.
  • Determine criteria for key business terms.
  • Request proposals from selected payers.
  • Negotiate key business terms.

Phase 4: Implementation

Establish a monitoring process and commence performance

  • Establish critical reports to manage the population.
  • Establish care management workflows.
  • Establish regular data feeds from payer.
  • Regularly educate providers on progress.