Client Profile
- North East US
- 4 Hospitals
- 700+ Beds
- 130 Physician Practices
- HIS System: EPIC
The Challenge
The PMMC Client, located in the North East US, is a clinically integrated network of physicians and hospitals that work together to provide high-quality, efficient health services. They cover the spectrum of patient care from wellness and prevention to disease and care management. Their network includes four hospitals and over 130 physician practices. Their mission is to be an integrated network of academic and community providers recognized for high-quality care and unparalleled satisfaction. A client since 2001, their PMMC Client Performance Manager described, “I would characterize the relationship as more of a partnership”.
The Associate VP, Contracting & Provider Services, has been with the client for 17 years. The hospital system and physician groups – and specifically their team of Managed Care experts – have made it a priority to make sure they understand the expected reimbursement from all of their commercial payer contracts. Without the proper software to handle the volume and complexity of these calculations, this part of the Managed Care role would be extremely difficult. For as long as their VP, Contract & Provider Services has worked with the system, his team of 5 (including directors and analysts) have relied on contract modeling software to calculate these complex terms.
Background Perspective
A PMMC client even before their VP arrived, he took the initiative to leverage the solution to its full capability. He originally managed the models himself, but as the system has grown, so has his team. Two additional members of his team have been trained to use the software as well. With so many commercial payers to manage, the VP and his team needed a way to validate that the contracts they agree to align with the organization’s revenue expectations. They rely on PMMC’s software to validate the expected reimbursement from its payers.
In total, the clients team models approximately 100 proposals and counter proposals on an annual basis. The VP describes PMMC’s contract modeling software as “the source of truth.”
The Outcome
The clients team negotiates every commercial contract by using PMMC’s contract modeling software.
Sample Payer Scorecard
Payer scorecards help healthcare providers understand payer performance and identify opportunities for re-negotiating contract terms
“It is difficult to measure the exact number of dollars that Rush Health has saved”, stated the VP and he is confident they have “generated millions of dollars in the system.” The speed of the software has also proven to be beneficial. For smaller payers, the models can be completed in a matter of minutes. For larger and more complex payers, the models can be run in less than 30 minutes. “This has been a great tool for us and we feel very confident in the software,” the VP concluded.
