Managed care directors negotiate payer contracts without clear visibility into how contracted rates compare against Medicare benchmarks or peer health system performance across service lines. Fee schedule complexity across dozens of payer contracts and DRG-based arrangements makes it difficult to identify underpayment patterns without time-consuming manual reconciliation. Value-based care contract performance is evaluated retrospectively, when opportunities to influence shared savings calculations have already passed.
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Managed Care Director modeling payer contract performance and renegotiation scenarios across 15 commercial payer contracts for a regional health system
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Managed Care Finance
Benchmarks contracted rates against Medicare and models the revenue impact of renegotiation scenarios.
Revenue Cycle Director
Identifies underpayment patterns from payer remittances and flags discrepancies against contracted rates.
Contract Compliance Auditor
Audits payer compliance with contract terms and flags systematic underpayment patterns.
Compare contracted rates against Medicare benchmarks and peer performance. Model value-based care scenarios and identify underpayments across fee schedules.
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Aetna is reimbursing orthopedic and cardiology service lines at 118% of Medicare versus a 142% peer benchmark, an underpayment of about $1.9M annually, and remittances show systematic shortfalls against contracted rates on 9 high-volume CPT codes. Recommend prioritizing the Aetna renegotiation; a modeled 5% rate lift recovers roughly $640K with minimal volume risk.