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Managed Care Strategic Repositioning and Revenue Enhancement Services

Managed Care FFS and Value-Based Strategies | Pricing/Reimbursement |
Analytics and Negotiations Support | Payment Innovations

Strategic Financial Imperatives: Our Perspective 
The forces affecting the healthcare industry across the country are compelling administrative and clinical leaders to make critical strategic, financial and operational decisions with respect to “how” and “where” patient care will be delivered, as well as its impact on revenue mix, volumes, and ultimately margins. With payers leveraging new data, steerage, and denial tactics, such trends will increasingly require leaders to establish a new negotiating playbook. Instead of thinking about “how I get paid in aggregate (or vs. Medicare)” leaders need to be asking “How much do I get paid for each service, in each care setting, and under which payment rules?”. At Guidehouse, we equip providers with the data, tools, and expertise through our revenue portfolio rebalancing solutions to achieve successful strategic revenue planning and negotiations for the long-term.   

Our revenue portfolio solutions address the complexity of:

  • Changing rates (public and commercial)
  • Shifting volumes and demographics 
  • The introduction of CMS price transparency rules for provider and payers
  • Shifts in public policy at state and federal levels
  • Mining for meaningful insights to empower organizations in negotiations and strategic decision-making
  • Post COVID-19 pandemic market and competitive environment changes

These conditions have created increasing uncertainty for provider organizations regarding their current and future revenue models (i.e., the operating framework which generate revenues for the provider organization). The revenue model has become even more complex with the introduction of value-based payments (VBP) by the national and larger regional health plan payers, regardless of their readiness for VBP, will have a wide-ranging impact on an provider organizations’ overall clinical and financial operations as well as strategic growth initiatives. 

Any provider that lacks a well-defined revenue model (i.e., managed care, revenue cycle and patient retention/growth for volumes) strategy, integrated with their clinical and administrative operation, will have difficulty maintaining margins, investing in growth, and sustaining operations. Conversely, a provider that has a well-defined, strategically aligned, and forward-looking revenue model plan in place, will position themselves to manage future transitions. Such a plan can empower provider organizations to maintain or improve margins, invest in strategic growth opportunities, and sustain overall enterprise economics.

About Our Practice 
Guidehouse has one of the largest and most experienced managed care strategy/pricing practices in the industry—fully aligned with our leading revenue-cycle solutions to offer comprehensive solutions to the forward-looking CFO. Our clients include top national and regional health systems, academic medical centers, large physician enterprises and clinically integrated networks/accountable care organizations/physician-hospital organizations as well as regional and national payers. Our projects range the payment model continuum from strategy and pricing on fee-for-service, to new value-based payment models, to emerging integrated payment models and helping clients prepare for next generation operational strategic performance.

How We Team with Your Organization to Develop and Implement the Right Solutions to Your Challenges and Opportunities

Our managed care solutions practice provides services across the full payer-provider contracting cycle with a data-driven and future-focused strategic approach. Our revenue portfolio solutions are organized by answering key questions that CFOs ask. The solution includes:

  • Diagnostic assessments and understanding of revenue deconstruction and driver dynamics
  • The development and implementation of advanced revenue rebalancing/strategic pricing models across a provider organizations payer revenue portfolio
  • Managed care rate benchmarking and payer specific contracting strategies and tactics
  • Managed care operations redesign
  • Development/implementation of sophisticated dynamic pricing and total cost of care pricing and negotiation strategies
  • Development of payer relationships/strategic alliances
  • A broad range of managed care contracting strategies across commercial, Medicare Advantage and managed Medicaid payer lines of business

While we have a broad range of solutions and services available to clients, our focus has always been first and foremost, on meeting the needs of the client. Solutions are then defined around the client need. We adapt existing or build new solutions to successfully meet client needs. 

If your organization needs traditional blocking and tackling managed care services diagnostics to understand how it affects your revenue, improve contract yield performance across the revenue cycle or next generation operational and strategic pricing models to improve your competitiveness and margin performance, we can assist.

 

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If you are interested in knowing more about Guidehouse and how our expertise can support your toughest challenges during this period, contact our experts.

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