A payer's livelihood, and the welfare of its members, depend on building a provider network that promotes member growth, retains high-quality providers and satisfies regulatory requirements. To accomplish these goals, the network needs to aggregate the right number and mix of providers and services, the right geographic distribution and the right incentives to give their members access to quality care at an affordable cost.
Cost and margin pressures, managed care, consumer demands and quality-linked payments exacerbate historically fractious relationships between payers and providers. Lack of clarity concerning contract terms can lead to reimbursement disputes. Inadequacies in administering contracts cause inaccurate and untimely claims payment, resulting in operational inefficiencies and consumer dissatisfaction. Bringing improved methodology to negotiating and administering provider contracts benefits all healthcare stakeholders.
Subject matter specialist
US Healthcare Payer Practice