Managed Care Negotiations and Strategies

• Pay-for-reporting and pay-for-performance: Quality reporting and incentive bonuses layered on fee-for-service.
• Upside-only shared savings: Retain FFS; share in savings if quality and total cost targets are met.
• Two-sided/shared savings with downside risk: Higher upside in exchange for loss liability when targets are missed.
• Bundled/episode payments: Fixed price for a defined episode (prospective or retrospective), often with warranties.
• Partial and global capitation: Prospective payments (professional, primary care, or total cost of care).
• Direct-to-employer (DTE): Contract directly with self-funded employers for bundles, centers of excellence, primary care capitation, and steerage programs.

We help design and negotiate shared savings programs that align incentives while protecting your organization.

• Benchmarking and trend: Baseline selection, regional vs provider-specific, trend methodology, rebasing limits.
• Risk adjustment: HCC/RAF approach, coding integrity guardrails, materiality thresholds, retrospective vs prospective locks.
• Savings/loss mechanics: Minimum savings/loss rates, sharing percentages, caps, risk corridors, withholds, timing of interim and final reconciliations.
• Quality gates: Measure selection, weights, HEDIS/Stars alignment, SDOH/equity metrics, validation, exceptions.
• Attribution: Passive vs active choice, plurality rules, leakage handling, episode vs population attribution.
• Stop-loss/reinsurance: Attachment points, catastrophic carve-outs, specialty drug treatment, transplant exclusions.
• Data rights: Frequency and format of claims/encounter feeds, portal access, data validation, audit rights, PHI use.
• Carve-outs and exclusions: Outliers, new tech add-ons, high-cost drugs, site-of-service, post-acute policies.
• Payment integrity: Overpayment definitions, offsets/recoupments limits, appeal timelines, extrapolation controls.
• Term/termination: Trigger events, cure periods, wind-down, continuity of care and data transition.

• Stark and Anti-Kickback value-based exceptions/safe harbors; CMP gainsharing rules; fair market value and commercial reasonableness.
• State insurance and risk-bearing organization (RBO) requirements, capital/reserve standards, DOI filings.
• Antitrust for CIN/IPAs (clinical integration, messenger model), and payer contracting do’s/don’ts.

We help craft bundles that drive predictable cost and quality without unintended liability.

• Episode definition: Triggers (DRG/CPT/ICD), look-back/forward windows, readmission and complication policies.
• Price and case-mix: Severity tiers, implant/device pass-throughs, outlier thresholds, wage index/market adjustments.
• Inclusions/exclusions: Professional fees, post-acute, imaging, DME, pharmacy (white/brown bagging), telehealth.
• Warranties: Duration, covered failure types, patient factors, shared accountability with vendors.
• Network and leakage: Preferred post-acute networks, steerage, referral management, COE designation.
• Quality/outcomes: PROMs/PREMs, infection/readmission rates, safety metrics; data sources and validation.
• Gainsharing models: Distribution methodologies with surgeons/clinicians compliant with Stark/AKS/CMP.

Self-funded employers seek transparent, high-value arrangements. We build compliant DTE strategies that lower total cost and improve member experience.

• Centers of Excellence bundles with travel benefits and warranties.
• Primary care capitation/advanced primary care and on-site/near-site clinics.
• Specialty care bundles and navigation; episode guarantees; maternity bundles.
• Reference-based pricing with wrap networks and balance-bill protections.
• Pharmacy strategies: PBM pass-through, outcomes-based contracts, specialty carve-outs.

• ERISA fiduciary duties, plan document/SPD updates, wrap documents.
• Gag clause attestation, hospital/plan price transparency, RxDC reporting alignment.
• Stop-loss alignment: Mirrors, lasering, disclosure, reimbursement of value-based adjustments.
• TPA, network, and PBM contracts: Fees, data access/ownership, audit rights, performance guarantees.
• Member communications, steerage incentives, NSA surprise billing compliance, IDR preparedness.

• Financial protections: Stop-loss/reinsurance, risk corridors, withholds, reserves, true-up caps.
• Delegation oversight: UM/CM, credentialing, claims, care management, quality reporting, data security; robust delegation and monitoring provisions.
• Governance and distribution: Savings/gainsharing formulas, physician compensation alignment, FMV support.

• Data and reporting: Encounter integrity, timeliness SLAs, file layouts, error-resolution rights.
• Coding and risk: HCC strategy, compliance plan, audit readiness, education.
• Quality performance: Measure selection, baseline setting, improvement targets, bonus pools.
• Care model build: Referral management, post-acute networks, site-of-care optimization, pharmacy integration.
• Dispute readiness: Documentation, root cause analysis, corrective action plans.

• Payer disputes: Underpayments, offsets, retroactive denials, payment integrity audits, extrapolations, prompt-pay interest, network terminations.
• Government programs: ACO waivers, MSSP and ACO Reach participation agreements, OIG/CMS inquiries, repayment strategies, self-disclosures where appropriate.
• No Surprises Act: IDR strategy, batching/submission, medical necessity and pricing defenses.

• Health systems, hospitals, ASCs, physician groups, behavioral health, home health and post-acute.
• ACOs, CINs, IPAs, MSOs, TPAs, direct-to-employer networks.
• Pharmacies (specialty, infusion), telehealth/digital health, device and life sciences collaborators.
• Self-funded employers and COE programs.