Attention!  Hospital and Health Plan Executives Responsible for Negotiating MCO and Hospital Agreements

Hospitals and managed care organizations (MCOs) are taking a more collaborative approach to ensure that their negotiated terms produce the financial results that they expect. In the recent past, hospital and MCO agreements have included significant changes in payment methodologies as the parties move toward episode based reimbursement terms.

In order to successfully negotiate a new agreement, both parties must understand the impact of the proposed financial terms. This typically involves applying the proposed contract payment methodology and terms to historic claims data and comparing the projected payments to the current reimbursement. While the concept is simple in nature, in practice the complexities of hospital billing result in significant differences between data sets used by the health plan and the hospital.

Through the use of a case study from an actual negotiation between a large Midwest hospital and MCO, participants will gain an understanding of the following:

• The critical elements of modeling a hospital agreement

• Common issues that can misstate charges or modeled reimbursement

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