OVERVIEW
Hospitals face persistent challenges in maximizing reimbursements due to opaque payor contracts and limited visibility into negotiated rates. The lack of actionable, comparative data results in less-than-ideal contract negotiations and missed revenue opportunities.
CHALLENGES
- How can hospitals and health systems determine if they are underperforming in payor reimbursements compared to market benchmarks?
- What indicators suggest that current payor contracts are not optimized?
- How can leadership identify gaps in reimbursement rates compared to sister facilities in their market?
APPROACH
HSG’s Insights to Action Methodology takes clients through six key steps to identify problems and create long-lasting solutions.
DATA ACQUISITION
What data do we aggregate to solve the problem?
Aggregating machine-readable files across hospitals and payors is far more complex than it appears on the surface. Every hospital and payor, whether a large national carrier or a small regional plan, publishes data using different structures and naming conventions, making it difficult to create a unified dataset without significant preprocessing. The sheer volume, inconsistency, and variability of these files require a disciplined approach to standardizing, cleaning, and organizing the information before any meaningful analysis can occur.
As such, HSG strives to:
- Aggregate machine-readable payor transparency files (MRFs) from both the client hospital, peer institutions, and applicable payors.
- Supplement with market benchmark data and published fee schedules.
DATA TRANSFORMATION
How do we extract information from the data?
- Standardize and clean input MRF data for consistency.
- Map reimbursement rates by provider, payor, and service line to enable direct comparison.
- Add key benchmark comparisons
- Visualize rate variances, outliers, and opportunities using dashboards and summary reports.
- Empower our provider clients to enter payor negotiations with actionable reimbursement data
PROFESSIONAL SERVICES
What expertise do we apply to find a solution?
- Develop tailored recommendations for renegotiation strategies and operational improvements.
- Work in partnership with clients to interpret data insights and identify actionable opportunities and develop negotiation strategies.
PACKAGING
How do we structure and apply our expertise?
Our team supports implementation every step of the way, equipping your organization with negotiation playbooks and payor engagement strategies tailored to your needs.
We offer flexible engagement models, whether you need a one-time analysis, ongoing monitoring, or a bundled advisory partnership. Our pricing is transparent and adaptable, with options for project-based or rolled in with your HSG Dashboard subscription to best align with your goals and budget.
DELIVERY
When and how do you receive solutions?
Data and insights are delivered through the HSG Dashboard platform along with other solutions. Data updates can be delivered on a quarterly or annual basis depending on need. HSG will also support development of a plan prioritizing recommendations for maximum reimbursement improvement.
IMPLEMENTATION & MONITORING
How do we provide ongoing support to your organization?
To ensure recommendations translate into measurable results, we provide hands-on support throughout implementation. Our team partners with your organization to guide contract renegotiations using data-driven insights and tailored strategies, assist your managed care contracting teams with interpreting and leveraging transparency data, and facilitate operational changes that drive sustainable reimbursement improvement.
- Establish key performance indicators (KPIs) such as average reimbursement rate, variance to like facilities, and percentage of Medicare rates.
- Set up regular review cycles to monitor progress and recalibrate strategies.
- Provide ongoing advisory support and data updates annually or quarterly
RELATED CONCERNS
As we move through the engagement, it’s common to uncover adjacent issues that directly influence reimbursement but extend beyond the original scope. These often include physician compensation structures that aren’t aligned with organizational financial goals, as well as gaps in charge capture, documentation, or coding accuracy.
By identifying these related challenges early, we help clients see the broader ecosystem of factors that shape financial performance and translate those insights into new, clearly defined problem areas to be tackled.
Want to see how your network is performing in payor reimbursements compared to market benchmarks? Reach out to DJ Sullivan at [email protected] to discuss and see if this solution could be a good fit for you.
