Revenue Integrity, Managed Care Contract Performance and Patient Financial Platform

The Vendor is required to provide revenue integrity, managed care contract performance and patient financial platform support automated, auditable, and operationally usable workflows across multiple hospital revenue cycle functions, including:
• Underpayment reporting and recovery based on modeled contract terms
• Payer contract management and performance analytics, including scenario modeling
• Patient financial estimates, projections, and financial assistance workflows
• Eligibility verification and payer/product matching, including coverage discovery.
- Requirement
1. Underpayment reporting and recovery
• Contract based expected reimbursement calculation at the claim and line level
• Identification and prioritization of payment variance and underpayments
• Reporting and dashboards with drill down capability
• Recovery and appeal workflow support with outcomes tracking
2. Payer contract management and performance analytics
• Configuration and maintenance of complex payer contract terms and amendments
• Continuous monitoring of payer compliance to contract terms
• “what if” modeling to assess financial impact of proposed contract changes
• Analytics to support negotiations and ongoing performance management
3. Patient financial statements, estimates and financial assistance
• Patient specific out of pocket estimates using eligibility and pricing inputs
• Automated estimate triggers and multi-channel delivery
• Audit ready reporting comparing estimates to actual reimbursement
• Automated financial assistance screening and patient self-service workflows
4. Eligibility verification and payer/product matching
• Real time and batch eligibility verification
• Coverage discovery to identify missing or secondary coverage
• Normalization and enrichment of eligibility responses
• Confidence scoring or equivalent logic to reduce false positives
5. Authorization management
• Prior authorization initiation, submission, and tracking across payer types (commercial, Medicare advantage, Medicaid managed care), including support for multi-code and multi-service requests relevant to oncology (e.g., chemotherapy regimens, radiation courses, surgical procedures, diagnostics)
• Real-time authorization status verification via payer portal integration, clearinghouse connectivity, and x12 278 transaction standards
• Rules-based identification of services requiring authorization, with payer- and plan-specific requirement logic tied to the patient's active coverage
• Automated authorization alerts and worklist prioritization flagging missing, expired, or expiring authorizations prior to service delivery
• Concurrent authorization monitoring and renewal workflow support for ongoing or multi-visit treatment courses
• Retrospective authorization identification and workflow support for services rendered without prior authorization, including appeal facilitation
• Authorization-to-claim matching to validate that services rendered align with approved authorization terms (approved codes, units, site of service, date range)
• Denial reason tracking and appeal workflow integration specific to authorization-related denials, with outcomes reporting
• Audit-ready documentation of all authorization activity, including request submissions, payer responses, status changes, and user actions
• Reporting and dashboards covering authorization approval rates, denial rates by payer and service type, turnaround time, and revenue at risk from pending or missing authorizations.