Managed Care Administration

PIC's Managed Care Administration Service provides our physician customers the benefit of our experience in the negotiation and administration of managed care contracts and assistance in clarifying the relationship between the cost of providing a service to a patient versus the amount physicians are compensated to provide that service. We seek to assist the physicians increase the quality of the care they provide by working with them to ensure proper financial support of their clinical services. It is our intent to accomplish each of these goals without increasing overall health care costs in the region.

PIC has established policies and procedures, and trained all staff concerning the need to compartmentalize each practice’s individual data. Each contracted practice’s confidential information is only used to negotiate on behalf of the practice that owns the information, and each contracted practice’s information is maintained separate and apart from the information of other contracted practices.

So as not to over burden already resource constrained practices, PIC seeks to obtain limited information in order to conduct an analysis. The information below provides a means of practice review to a level that will support those recommendations for practices change.

Accounts Receivable reports, current and aging
Contracts and Fee Schedules for the payers
A list of the most frequently billed CPT codes and the charge amount
Explanation of Benefits (EOB’s) to confirm rates stated in the fee schedules

Once the background information is deemed complete, an interview is conducted with the physician and/or the practice’s dedicated administrative personnel to determine the issues and concerns of the practice in connection with the practice’s managed care administration burden. Based on publicly available data concerning common managed care contracting issues, as well as PIC’s experience in the area, each contract is reviewed to ensure that it contains explicit language acceptable to the practice concerning but not limited to the following:

Fee schedules and time frame for fee schedule updates
Billing terms
Termination procedure for either party
Post Op global period
Coordination of benefits policies
Claims processing and claims appeals issues

This information is synthesized, in collaboration with the practice, into a payor specific contract negotiation strategy. The practice’s contractual portfolio is assessed simultaneously, and a short, medium, and long term payor participation strategy is formulated. Execution of the strategy is accomplished jointly between physicians, practice staff, and Partners In Care staff as each situation merits. Significant care and attention is paid to existing patient relationships and local employer impacts. Communication and advocacy efforts with patients, local employers, and local health insurance brokers are incorporated as appropriate.

For further information regarding this program, please contact us at 732-805-0400.

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