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Provider Network Contract Management
Contract management plays a significant role in provider networks. An effective contract management system ensures that contracts have the right payments, providers are held accountable for care outcomes, and clinicians work towards qualitative, patient-centric care. It involves defining appropriate, agreed-upon payment terms so that payers, providers, and provider groups can focus on care coordination and health management.
The healthcare industry supports the following contract payment types.
- Fee-for-Service
- Healthcare providers are paid a negotiated amount for each service they perform. The amounts are based on the comprehensive fee schedule definition set up by Centers for Medicare and Medicaid Services (CMS). Example: patient visits.
- Category-Based Payment
- Healthcare providers are paid based on a defined negotiation for each procedure category that they work on. Example: vaccines.
- Percentile-Based Payment
- Providers are paid based on the percentile range that the member falls into. Each percentile range has a separate fee, which is determined by factors such as the member's age. For the same service, the provider is paid a different amount for members in the 50th percentile and 75th percentile.
- Shared Savings
- The payer shares the profit and loss with the provider and provider groups. The payment terms are dependent on the forecasted expenditure and the profit or loss percentage for the defined time period. This payment type is generally seen in an Accountable Care Organization (ACO).
- Capitated Payment
- Providers are paid a fixed amount per member every month for a fixed set of services. As part of the program, the payer can also decide to withhold some amount and pay it later as a bonus amount based on the performance.
- Bundled Payment
- Providers are paid for each procedure bundle they work on. Bundles are a group of procedures that are offered together by the provider. Bundled payment is tier-based and can have different prices depending on the services and care offered. Members and payers choose the bundle category that works best for them. Example: Basic, mid, and premium tier.
- Preventive Care
- Providers are paid a bonus when they reach an agreed upon target such as reducing the admission or readmission rates by a certain percentage.
- Contract Management in Health Cloud
Health Cloud's comprehensive contract management solution provides payers, providers, and provider groups with a single, integrated system for recording contract information. The ability to find the information you need and manage fee schedules all in one place makes your job easier and ensures faster access to patient care. - Add Fee Schedule Information for Fee-for-Service Contract Payment Types
As an actuary, you can create a library of fee schedule information based on the comprehensive list published by CMS (Centers for Medicare and Medicaid Services). Your contracting specialist can then use this fee schedule information as a base to define the payment terms for contracts of Fee-for-Service payment type. - Create a Payment Agreement and Define Payment Terms for a Contract
Use Health Cloud's comprehensive contract management solution to define the payment agreement terms from within the context of a contract.
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