Managing Payors, Contracts, and Reimbursement in a Changing Healthcare Landscape

Updated: Jul 16

By: Kyle Crow, Regional VP of Sales

It is well known that receiving appropriate reimbursement for healthcare services is fraught

with complexities and challenges for hospital organizations. The current pandemic has wreaked further complications across the industry due to volatile patient volumes, canceled elective procedures, and at times, surging ICU counts. The healthcare industry has been forced into a state of upheaval and hospitals, insurers and government payors have all introduced patchworks of rule changes to address the challenges brought by the COVID-19 outbreak.

The Department of HHS has allocated over $175 billion to distribute to hospitals struggling to combat the coronavirus. Many private insurers are waiving pre-auth requirements and coronavirus related patient hospitalization costs. In the short term, these distributions and temporary waives are prudent and necessary, but what is less obvious are the expanded documentation requirements needed to qualify for these temporary relief measures. In an already bogged down system, hospitals will need to be even more diligent and in lockstep with their payor partners than ever to maintain revenue.

In this new normal, hospitals will need to place a renewed focus on granular and broad-based payments data from their health plan payor partners. Most important of these metrics include:

- Encounter level payment amounts, including adjustment amounts and percentages per


- Health plan response times rated in aggregate and against other payors

- Overall denials rate per payor and average denials per claim

- Average payments by claim, separated by inpatient and outpatient data

In monitoring these metrics, hospitals can retain superior visibility to the operations of the hospital as well as their associated health plans. Understanding these metrics will help guide future initiatives across the organization and assist in driving the appropriate patient mix to maximize patient care and revenue. Armed with this data, hospitals can have earnest conversations with their payors to establish equitable partnerships for both parties and better understand how each side works to achieve shared, desired outcomes.

Does your facility lack visibility to these vital metrics? Are these metrics and other essential data easy to access, filter and present in an easily understood manner, all in real time? Softek provides several tools to address these data gaps, including the soon to be released ‘Payor Report Card’ providing unparalleled insights to health plan reimbursement metrics.

What does Softek® do?

Softek's mission is to help hospital systems get the most out of their investment in Cerner® Millennium™. We do this by providing innovative software solutions and consulting services that can achieve more together than either can alone.

At Softek, our team of innovators and software developers brings expertise beyond the ordinary to every client. Our experts are involved with Cerner® Millennium™ hospitals throughout the country consulting clients so they can optimize system performance and revenue integrity.

Softek delivers a full suite of consulting services and software solutions to assess and optimize EMR system performance, including revenue cycle integrity and patient accounting.

Softek was awarded 2020 KLAS Category Leader for Revenue Cycle Optimization.

Let’s talk to see how you can get the most out of your Cerner® Millennium™ system.

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