Network Contracting & Evaluation

Network Contracting & Evaluation

Network management is under scrutiny as medical costs and competition for membership continues to increase. While there are many factors contributing to the rising cost of health care, unit cost increases (i.e., the amount paid to hospitals and physicians) have been the primary contributor for commercial private payers for the past several years.
Network managers strive to balance the competing priorities of broad network access while maintaining competitive contracts with their network physicians and hospitals. In addition, technology advances and the desire for health plans to identify and reward the highest quality health care providers have resulted in added complexity to payment methodologies.

A payer’s ability to develop and maintain a competitively priced provider network is critical to minimizing cost increases and increasing membership. Knowing how competitive your provider contracts are relative to your competitors’ contracts is extremely powerful when entering contract negotiations. Arming yourself with knowledge about a provider’s overall financial performance and their financial performance related to your contract helps to level the playing field and initiate productive dialogue in negotiations.

The ability to accurately predict medical costs is nearly as critical to health plans as maintaining a competitive cost structure through their network contracts. New, complex payment methodologies and pay-for-performance (P4P) initiatives can hinder efforts to accurately forecast medical cost levels. Reden & Anders can assist in evaluating and quantifying the financial impact of new provider contracts and changes to existing provider contracts. 

Reden & Anders has a variety of tools and services to assist payers in the provider network management process including:

    • Developing network contracting strategy
    • Identifying negotiation opportunities and develop prioritization based on the provider’s financial performance and the competitiveness of the current contract
    • Supporting network management during negotiations
    • Assessing financial impact of various contract changes and scenarios
    • Measuring and sustaining contract performance

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Contract Evaluation Solutions
Reden & Anders has a wealth of expertise to assist you in evaluating the affect of new provider contracts on unit cost levels. Our team can adapt to best meet your contract analysis needs. We offer the flexibility to manage the entire contract analysis function, build tools for health plan staff to use internally, or simply provide peer review of current processes and tools.
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Contract Maintenance Solutions
As experience emerges under new contracts, Reden & Anders can provide analysis and tools to help determine how this experience compares to projections prepared during the negotiation process. We can break down and quantify the various factors contributing to overall unit cost trend, including how increases in a provider’s charge master affect overall reimbursement.
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Negotiation Support Solutions
Reden & Anders translates the competitive data contained in ReimbursementAnalysis into a powerful message for a payer—and helps them bring more to the negotiating table. This critical information can help keep unit cost trends in check as contracts are renewed. Furthermore, we can work with your network management team to develop a contract structure that best meets your health plan’s goals and minimizes uncertainty and risk in provider reimbursement.
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ReimbursementAnalysis™ Solutions
ReimbursementAnalysis is a detailed, consultative analysis providing a comparison of contracted reimbursement rates for payers. Reden & Anders consultants use ReimbursementAnalysis to provide payers with actionable, competitive financial data for negotiating provider contracts. Using ReimbursementAnalysis helps level the playing field in provider negotiations.
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