MCO PROCESS

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Phase One  (3-5 Months)

Peregrine Healthcare will obtain a list of the client’s top payors from the billing department and will identify which payor contracts are set up as individual contracts versus group contract.
Contracts and fee schedules obtained from payors will be evaluated and a MCO (Managed Care Organization)
Summary Sheet will be compiled. A fee schedule analysis will be completed based on the practice’s top codes and compared to current year Medicare rates.
IPA, PHO and ACO relationships will be identified.
It is difficult during the first phase to make recommendations on new contracts or amendments because Peregrine is still reviewing the client’s payors as a whole. If a new contract or amendment comes in, Peregrine will attempt to obtain necessary information in order to make recommendations.
 
Phase Two (3-5 Months)
If individual contracts are in place, Peregrine will discuss the possibility of moving to a group agreement with the payor only if the rates are just as favorable as or better than an individual contract. If a group contract is offered, Peregrine will review the contract and move forward.
Peregrine will evaluate the relationships with the IPAs and PHOs to make recommendations on overall practice reimbursement. This could mean moving the practice to direct contracts if the rates are better.
Peregrine will initiate any fee schedule negotiations with health plans that reimburse below par.
If it is identified that the practice is not participating with some area plans that may be beneficial to the practice, Peregrine will reach out those plans to obtain contracts, review against top codes and make recommendations to the practice.
 
Phase Three   (Items in Phase 2 often roll over and continue into Phase 3)
Periodic EOB reviews to ensure payors are paying at contracted rates and that we have the most current fee schedule on file.
Review and evaluate new contracts and fee schedules that come into the practice. Compare with industry norms. Make recommendations to client.  Initial negotiations when applicable.
Maintenance of on-going relationships with existing Managed Care Organizations on behalf of the practice.

Peregrine will review practice data yearly to determine loss or gain in key CPT code areas and provide that information to the client.
Periodic fee schedule negotiations with health plans as needed based on the market norms.

MCO Process
Managed Care