Managed Care Advisory Services

Ensuring your healthcare organization is being competitively compensated and following best practices is vital when negotiating reimbursement rates with payers and managed care organizations (MCOs).

At Baker Tilly, our team of professionals understands the intense pressures providers face and can help organizations conform delivery models, operational plans and reimbursement strategies to remain competitive and financially stable.

Our solutions

The changes in healthcare are inevitable and providers are tasked with the unique challenge of balancing its payer portfolio, continual movement of services to an outpatient model, empowered consumerism and shifting payment models, while at the same time, improving patient access and outcomes at a lower cost.  

Baker Tilly provides a full range of managed care consulting solutions that are customized to fit the individual needs of our clients and that can help providers quickly adapt and transform their strategy, operations and reimbursement structures to remain competitive and viable in an evolving market. Simply investing in technology alone is not enough to facilitate meaningful change; through the implementation and full understanding of data analytics, strategic planning and interoperability, and next generation payment models, providers can begin to make more informed, data-driven decisions that can lead to financial success. 

With our diverse client portfolio of fully and self-insured health plans, hospitals and health systems, senior services, behavioral health, MCOs, life sciences, and venture capital and private equity organizations, our team is able to offer real-world insight into today’s complex healthcare environment that helps your organization on its financial sustainability journey.

Charge description master analytics

Federal pricing transparency regulations are intended to help prevent unexpected medical expenses by providing consumers with the estimated cost of services before they receive care. Although this helps increase competition among providers, there are challenges to understanding and complying with pricing transparency while also incorporating it into existing managed care arrangements. Baker Tilly can help evaluate your current methodologies and pricing, as well as validate billing codes, to reassure you that charge structures and pricing are aligned with local marketplaces to provide your organization the security that it is well-positioned in your local market Baker Tilly’s price transparency solutions also offers a machine-readable file assessment to determine whether your price transparency files comply with the required files specifications.

Managed care benchmarking

Understanding where your organization’s performance compares in the marketplace can help you develop proactive contracting arrangements that can advance your payer relationships well beyond the traditional fee-for-service (FFS) platforms. Baker Tilly is able to use empirical claims data, as well as emerging market intelligence, to develop next-level payment models that align your prices with marketplace competitors in order to retain business, optimize reimbursement and yield sustainable financial returns.

With the help of our experienced professionals and our licensed Merative database – one of the largest proprietary U.S. claims databases – we are able to provide you with the information that will help your provider organization benchmark against competitors. These benchmarks are arrayed from the 25 to 90 percentile to display the progression and dispersion of rates across your local market. Whether you want to know about your geography’s disease prevalence, average commercial payments for procedures, utilization patterns, or other specific insights, Baker Tilly and Merative are able to offer your organization the most up-to-date data so that you can make more informed and confident decisions.

Performance and risk-based assessment and contracting

Understanding where your organization is positioned in the market and what risks are the best fit are paramount to succeeding when implementing value-based care (VBC) arrangements. Proactive planning and understanding the dynamics of risk when transitioning as a new entrant, or when moving to the next level of value-based contracting, are key to mastering the Triple Aim approach of improving patient experience, improving health outcomes, and reducing the per capita cost of healthcare.

Baker Tilly can help your healthcare provider organization prepare and enhance the performance of risk-based arrangements by identifying gaps and opportunities in your current program. Our team of professionals are able to assess your organization’s level of readiness to implement VBC contracts while also identifying key transformation activities required to realign and optimize risk-based strategies, processes and enabling tools. Our framework consists of four unique phases, which can be leveraged individually, in any combination, or all together based on an organization’s level of VBC program maturity:

  • Feasibility: Determining a provider’s readiness to implement a VBC arrangement by assessing the current state of the organization’s operational and technical capabilities, as well as its external stakeholders and marketplace factors.
  • Design: Establishing a VBC program that can be agreed upon by the provider and health plan partners, and that incorporates detailed business rules and capabilities that are required to operationalize the program. 
  • Enablement: Implementing and helping the people, processes, and technology required to build the new, or expanding an existing, VBC program that is operational and efficient. 
  • Monitor: Ensuring providers have the necessary tools to track the success and optimize the performance of their existing VBC programs. 
Bundled and fee-for-episodes payment design and modeling

Based on case rate payment methodology experience, healthcare organizations can often find that one of the easiest transitions to VBC is through bundled and fee-for-episode payments. Baker Tilly can evaluate the readiness of your organizations and identify which payment models are the right fit. Our Bundle and Episodic Payment (BEP) tool, in collaboration with our revenue cycle management (RCM) and optimization services, can help determine which procedures, healthcare organizations and reimbursement structures are a good fit, as well as identify the projected financial risks that are associated with the bundled or episodic service. 

Utilizing analytics in managed care contracting negotiations provides a data-driven approach to understanding patient demographics, utilization patterns, reimbursement rates between payers and other provider organizations, low and high performing service lines, physician performance and payer performance. By leveraging these insights, healthcare providers can strategically structure contracts that align with their strengths, enhance efficiency and improve patient outcomes. 

At Baker Tilly, our team of managed care contracting specialists take a data-driven approach that helps healthcare providers enter negotiations fully prepared. Through the utilization of our exclusive contract management tool and user-friendly analytics platform, Service Line Data Signs, healthcare providers can gain enhanced insights into their service line margin performance and manageable, direct expenses, as well as gain a better understanding of reimbursement rates of their competitors. This preparation equips organizations to confidently engage in negotiations with their contracted payer partners, making them well-equipped for productive discussions. 

Service line analysis

As inpatient hospital surgeries continue to migrate to the outpatient patient setting, ambulatory surgery centers and minor surgical procedures provided in private physician office surgical suites are expected to grow at 5.6% annually and reach an estimated value of $84.1 million by 2027. Healthcare providers will be required to keep up with trending market demands, adjust their prices and manage where and how they provide services to consumers. Baker Tilly can assist providers seeking to retain and/or increase patient revenues and remain competitive with strategic benchmarking market analysis that can help businesses anticipate and understand the shifts of healthcare services within local marketplaces.

Managed care predictive modeling

Healthcare providers have the greatest chance of becoming, or remaining, financially sustainable when they are acting proactively, rather than reactively, to the evolving healthcare marketplace. Understanding the return on investment and identifying economic vulnerabilities are also crucial when making future financial decisions. Baker Tilly can help your organization develop short-term and long-term strategies with the use of predictive analytics by analyzing and modeling potential marketplace scenarios, which can help drive predictable financial results – through profitability or by mitigating loss – to better understand the financial implications of the marketplace and so they can better prepare for the future. 

Fee-for-service continues to play a primary role in managed care contracting and is projected to remain a viable payment structure option for healthcare organizations. Understanding the impact of market trends, having advanced analytics capabilities, engaging with stakeholders and executing a well-designed strategy are all crucial to successful contract negotiations. Baker Tilly is able to assist in navigating the challenges of rate negotiations, payment rules and methodologies, revenue forecasting and contract language development that affects revenue. Our team provides the experience required to effectively evaluate and manage healthcare organizations' managed care agreements to improve their profitability.

Providers must actively oversee their managed care contracts, relationships and payments while also remaining focused on other pressing issues and commitments. Baker Tilly can provide your organization with a range of outsourced interim managed care support solutions, including: 

  • Long-term and short-term staffing support 
  • Calculating model reimbursement rates 
  • Organizing department functions and structures 
  • Developing contract management databases 
  • Tracking contract performance and corresponding revenue 
Expense reduction strategies

Providers are actively exploring various avenues to enhance revenue while also implementing measures to curtail expenses. Assessing physician staffing levels, performance metrics and compensation structures presents an opportunity not only to trim healthcare expenditures but also to bolster overall revenue. This dual approach can drive down healthcare expenditures while concurrently enhancing the quality of care and bolstering patient experiences, aligning with the requirements of an increasingly empowered consumer base. To assist in this endeavor, Baker Tilly offers comprehensive support, including conducting thorough cost-benefit analyses and performance evaluations. These evaluations enable the identification of optimal high-performing service lines and staffing models that strike a balance between reducing excessive costs and augmenting revenue streams associated with healthcare delivery. 

Integration strategies

Attracting payers and securing VBC contracts requires providers to demonstrate they have an engaged physician organization to deliver on their commitments. To succeed in a VBC environment, providers must establish and demonstrate their medical professionals are integrated and invested in the leadership of the organization, and are high-performing providers that deliver quality care with optimal outcomes. Baker Tilly can advise which type of physician organization model will produce the most desirable results. We have worked with clients to help create and design the following physician alignment models: 

  • Clinically Integrated Networks (CIN) 
  • Integrated Delivery Networks (IDN) 
  • Physician-Hospital Organizations (PHO) 
  • Patient-Centered Medical Homes (PCMH)  
  • Independent Physician Organizations (IPA) 
  • Partially Integrated Medical Groups (PIMG)  
  • Fully Integrated Medical Groups (FIMG)  
  • Management Service Organizations (MSO) 

In addition, our specialists assist with developing strategies and roadmaps to help providers become more organized on their path towards success in value-based contracting. 

Due diligence

Private equity and venture capital investment in the healthcare industry continues to increase at an exponential rate. With the financial effects that stemmed from COVID-19 acting as a catalyst, many businesses are increasingly considering the decision of combining with or selling, their practice to avoid insolvency. Baker Tilly understands both the private equity and healthcare industries and has the experience needed to advise organizations on their financial viability and healthcare investments. Our team has a comprehensive set of services to help organizations who are considering M&A strategies through our due diligence, valuation and tax planning solutions.

Healthcare feasibility study

For organizations looking to add to their growing provider portfolios, healthcare organizations want to be certain about which approach will be best, whether it is through expansion, joint venture, acquisition or new development. Furthermore, opportunities to provide new healthcare services, capture additional market share and increase patient revenue exist when an idea is turned into a viable plan. Baker Tilly can assist your organization with a wide range of solutions to help leaders make more informed decisions and develop comprehensive business plans, including market analyses, business projections and financial forecast.

Healthcare Data and Analytics for Financial Sustainability

Service Line Data Signs

Explore the transformative potential of gaining transparent and actionable insights into direct, controllable costs and revenue by leveraging your organization’s data through Baker Tilly’s easy-to-use tool, Service Line Data Signs.