The vendor is required to provide strategic managed care contracting consulting services to assist department in assessing the financial value of its medical managed care plan contracts.
- Hospital fee-for-service contract renewals:
• Perform financial revenue analysis of department hospital fee for service contracts with managed care health plans, by each line of business, that are slated to expire during calendar years 2025 - 2027.
• The financial revenue analysis findings, create reports that summarize department revenue collections compared to billed charges and expected payments
• Assist department staff with further analysis to determine potential root causes impacting any identified under-payments.
• Present rate proposal recommendations to department managed care contracts and finance teams for consideration.
• Advise and inform department staff of contractor’s formulation of contract renewal negotiation strategy decisions, as needed.
• Assist department with drafting hospital rate proposals to initiate negotiations with managed care health plan payers.
• Additionally, on an as needed basis, serve as lead negotiator with managed care health plans on behalf of county.
- Medical managed care health plan capitation agreements
• Analyze department overall financial performance with respect to its active managed care health plan capitated medical contracts by medical category of aid groups on a department enterprise-wide level and as needed by department ambulatory care practice sites and hospital facilities.
• Analysis shall include in-network and out-of-network utilization of assigned enrollees.
• Conduct a detailed financial performance analysis of ten (10) department capitated participating provider group (ppg) pods, identified by department.
• Provide summary of performance analysis and recommendations and options for adjusting financial risk arrangements of the ten (10) ppg pods, to mitigate revenue losses
• Assist and advise with the negotiation of existing capitation contracts.
• This may include development of capitation rate structures and financial arrangement proposals based on analysis performed pursuant to above, reviewing new or revised language of contract terms, and drafting capitation rate counter proposal executive summaries and key talking points for department lead negotiators use during health plan contract negotiations.
• Perform financial modeling to help inform the development of capitation rate proposals to negotiate new physician and hospital capitation contracts for new lines of business, including but not limited to serve medicare and medical dual coverage health plan enrollees.
- Professional service and hospital agreement expansions with strategic medical non-contracted payers:
• Perform financial revenue analysis of department professional and hospital services encounters provided to medical insured populations enrolled with department non-contracted capitated medical group and hospital payers.
• Present analysis findings in summary reports to brief department business and finance teams on non-contracted payer business volumes and average outpatient visit and inpatient per diem rates collected.
• Based on financial revenue analysis performed in, provide department business and finance teams recommendations whether department should pursue direct contracts with any identified strategic capitated medical group or hospital non-contracted payers.
- Contracting strategy for certain tertiary and complex services
• As business needs arise, assess current department billing practices for any of the following, which at a minimum shall include, complex surgeries, surgical implants, high-cost drugs, kidney transplant services, trauma, and inpatient and outpatient burn services.
• Provide recommendations to maximize revenue collection for services analyzed pursuant
- Hospital leadership-payer contract training materials
• Develop training materials to provide department leadership audiences overviews of hospital contracting best practices in managed care industry, which at a minimum shall include, contract strategy, contract terms and financial payment arrangements.
• Develop hospital leadership contract playbook to guide leaders in day-to-day operational decision-making concerning services provided to enrollees in connection with contracted and noncontracted health plan payers.
• Assist in the development and deployment of a payer contracting on-boarding curriculum for new department staff.
- Contract Period/Term: 12 Month
- Questions/Inquires Deadline: April 17, 2025