Managed Care Solutions for the Modern Hospital System

As healthcare is one of the most complex and expensive industries in the world, hospitals are constantly working to provide the best possible care for their patients while ensuring they are receiving maximum revenue for their services. Payers are notoriously challenging to work with, and hospitals often need to turn to outside help to receive full reimbursement for their services.

Understanding Managed Care

Managed care is the term used to describe the system within which hospitals and payers work together to provide care for patients. Payers are generally Medicaid, HMO, PPO, or other insurance providers. Their job is to ensure hospitals disperse proper treatment within each individual patient’s insurance plan. Conflict can and does arise when there is disagreement between hospitals and payers in terms of the treatments needed to effectively help a patient. When this occurs, the assistance of a managed care professional becomes critical to ensuring a hospital is paid for their services.

Using Managed Care Negotiators

Payers and hospitals enter into contracts that include treatment guidelines, payment schedules, approved doctor lists, and a myriad of other points. Contracts by their very nature are complex, and payers ensure theirs are no exception. This is because, like any business, they want to mitigate risk and maximize revenue, but in this case the providers, that is, the hospitals, end up taking on the risk when the system is not properly managed. Managed care experts including are specially trained to cut through the noise to break down exactly what is and/or should be paid to the hospitals. Contracts are deeply assessed, and results include recommendations on how to renegotiate the contract to include possible new policies and rate schedules to ensure a more balanced reimbursement structure from the hospital’s perspective.

Understanding personal health insurance coverage, physician restrictions, and payment schedules are difficult for most people to master. It should be no surprise that the same challenges exist for hospitals seeking reimbursement from payers for services rendered. Utilizing skilled negotiators specifically trained in managed care can help ensure hospitals receive the financial compensation to which they are entitled.