付款人的策略 Development, Reimbursement Assessment, 和 Negotiation Support

For more than 40 years, 伊利诺斯州 Institute for Addiction Recovery (IIAR), an affiliate of UnityPoint Health, has provided inpatient 和 outpatient services for adults struggling with addiction. IIAR offers alcohol, chemical dependency, 和 process addiction treatment services at four locations across central 和 northern 伊利诺斯州.

Faced with a 22% decrease in discharges between 2012 和 2014, driven by a variety of market factors, IIAR spent the next two years working to rebuild volume. 然而, its mixed contracting model—a combination of in- 和 out-of-network status with major payers—limited its ability to provide services to some patients as payers began restricting authorizations for out-of-network providers. Securing in-network agreements with additional payers was challenging because the responsibility for establishing 和 maintaining contracts for IIAR’s services was split across three entities with limited expertise in contracting for addiction medicine services. The complicated managed care process created operational challenges, contributed to a general sense of uncertainty among staff, 和 impeded IIAR’s ability to secure new agreements 和 negotiate increases to existing agreements.

IIAR engaged 心电图 to complete a comprehensive managed care strategy 和 reimbursement assessment. The goal was to establish new payer agreements, enhanced contract terms 和 reimbursement rates, 和 a more coordinated managed care contracting structure 和 process.

Our assessment focused on four key areas:

• In-Network Participation 策略: We analyzed IIAR claims data to identify those out-of-network payers with the greatest historical volume 和 potential for future referrals (based on each payer’s existing membership levels in the region 和 local market).
• Reimbursement Benchmarking Assessment: We developed a reimbursement model that compared existing reimbursement rates to regional 和 national benchmarks 和 identified opportunities for revenue improvement
• Negotiation Timeline 和 策略: Because multiple concurrent payer negotiations can be overwhelming, we developed a negotiation timeline 和 strategy that would allow IIAR to focus on priority payer negotiations first, secure needed volume 和 reimbursement increases, 和 then sequence negotiations with lower-volume payers.
• Managed Care Organizational Infrastructure: To simplify IIAR’s managed care infrastructure, we developed a recommended contracting structure that was more closely aligned with the existing UnityPoint system managed care department.

心电图’s managed care team worked closely with IIAR leadership throughout the assessment process to create a detailed managed care strategic roadmap that specified target reimbursement levels for IIAR’s future payer negotiations. The roadmap also included an infrastructure plan to ensure the managed care contracting function would continue to be supported on an ongoing basis.

心电图 was then asked to collaborate with the UnityPoint system managed care team to secure new in-network agreements 和 lead negotiations with high-priority commercial payers. As a result of the negotiations, IIAR realized reimbursement rate increases ranging from 5% to 21% 和 established new in-network agreements with two major commercial payers.