Healthcare Reform Driving Value Based Provider Contracting

Health plans realize that provider contracts and the information within them are critical to claims processing and correct provider service payments. Mistakes or errors within the health plans provider contracting process negatively affects their medical loss ratio, administration costs, and their provider and patient satisfaction.

With the growing complexity of provider contracts and the new requirements being driven by reform, it means that in order to have value-based provider contracts, the system and processes have to comprehend the performance and quality that will drive reimbursement methodologies. For example, health plans should have provider contract management systems and processes that allow for:

• Codified data to drive analytics and automated contract claims translation.
• Flexible contract definitions to drive standardization and reporting.
• Transparency to show the intent of the contract and strong audit capability.
• Codified performance criteria and measurement methods.
• Multi-stakeholder contracts that embody episodes of care.
• Automated workflow capabilities to support internal review and approval.
• Access to actual provider performance and real-time network intelligence to dynamical adjust payment models to align with actions taking place in the care environment.

The government and employers' continued pressure regarding payment and healthcare system reform will drive health plans to change how they operate. It will no longer be sufficient for a contracting system to simply manage documents; it will need to evolve into a system that incorporates intelligence from the network, provides transparency to providers and members, and integrates performance metrics from the field.