KBH Consulting Services
Katz Brunner Healthcare specializes in managed care strategic initiatives practical for providers in small urban and rural communities. Our philosophy centers on the assumption that each market is unique, requiring individualized strategy development to successfully address its goals.
Lost in the
Maze Called
Managed Care?
The ever-changing marketplace called “Managed Care” presents opportunities and challenges at every turn for providers, payors and consumers alike.
Addressing each decision is like entering a maze. Confronted by walls restricting options available; and doorways through which community hospital executives can navigate the maze successfully.
It is imperative that your organization be prepared, even before the challenges and opportunities arise, by having experience and practical knowledge readily available for guidance through the managed care maze of the day.
Among the many KBH Consulting Services available, some of the more frequent services utilized currently include the following:
- Managed Care Strategy Development
- Managed Care Pricing Analyses and Charge Master Strategy
- Fixed Rate / Package Pricing Development
- Outsourced Managed Care Functions
- Selection & Training Managed Care Director & Staff
- Expert Witnesses for Major Claims Disputes
- PPO, PHO, Branded Product Development
KBH consulting services are continually adapting as new maze situations present themselves. KBH clients benefit from KBH's broad experience facing similar mazes in other comparable settings.
Most KBH consulting services can be accessed on an ad hoc basis, without any long-term commitment from the client hospital and/or physician group.
Many KBH clients prefer the security of working with KBH on a retainer basis. They pay KBH a pre-determined monthly fee allowing the retainer client access to all KBH services at significantly reduced rates. Additionally, retainer clients have the continuity of KBH represention of their interests on an on-going basis in discussions with payors or other entities influential to managed care initiatives.
Managed Care Strategy Development
Utilizing market intelligence on all major payors in the market, KBH analyzes current local and regional market dynamics, reviews all existing managed care contracts, shares anticipated market trends and develops specific contracting strategies for the community hospital to use with each managed care payor and/or network.
Setting of Managed Care Objectives based on objective facility and market assessments, and managed care trends being confronted in similar rural or small urban community settings.
Market Intelligence Gathering for all major “payors” (e.g. self-funded employers, insurance companies, HMOs, PPOs, TPAs) currently in the local market area and those likely to enter in the near future. Reports include detail of payors and networks contracted at each hospital in your area, and relationships between managed care entities and local area employers.
Market Positioning Audit provides detailed research profiles for each payor and network in your area, summarizing general contracting strategy and typical contract terms. Each existing contract is evaluated for appropriate language and reimbursement criteria.
Medical Staff Contract Analysis evaluates existing and likely near future Physician / MCO contract relationships to avoid conflicting contracting strategies between the community hospital and other local area providers.
Managed Care Pricing Analyses and Charge Master Strategy
The increasing popularity of consumer-driven initiatives are increasing costs to consumers, leading them to “shop” for healthcare based on quality and cost. Government initiatives are also calling for more transparency in provider pricing.
Within this new frontier, KBH will work with your staff to develop a defensible pricing strategy that is both market competitive and fiscally responsible.
CDM / Charge Master Revenue Assessment:
A unique approach to pricing strategy, KBH utilizes a comprehensive combination of gross and net revenue goals, managed care contract limitations in conjunction with market benchmark comparisons to establish pricing recommendations for individual charge items.
In developing your customized pricing model, KBH accounts for limiters such as high-profile charge items, upper and lower change limits for departments or individual items, and Medicare threshold minimums.
This project enhances pricing consistency between departments and services while meeting revenue goals.
Inpatient Pricing:
- Pricing impacts and recommendations based on managed care reimbursement methodologies, such as DRG, Per Diem and Per Case.
- Strategic pricing recommendations by specialty and clinical service categories.
- Analysis of managed care components such as lesser of charges, stoploss thresholds and carve-outs.
- Development of Fixed Rate packages for specific elective procedures.
Ambulatory Surgery Pricing:
- Pricing impacts and recommendations based on managed care reimbursement methodologies, such as ASC, APC, or Specific Procedure Categories.
- Development of Fixed Rate packages for specific elective procedures.
Outpatient Pricing:
- Pricing impacts and recommendations based on managed care reimbursement methodologies, such as fee schedules, flat rates for ER or observation patients, etc.
- Evaluation of fixed rate reimbursement for common radiology procedures, such as CT / MRI / Mammography.
- Development of Fixed Rate packages for specific elective procedures.
Fixed Rate / Package Pricing Development
Both hospitals and physicians will need to be more "transparent" in their service pricing, disclosing more to the prospective patient of what they can realistically expect their hospital visit to cost.
KBH combines analysis of all or partial components needed to establish fiscally prudent fixed rates or package prices that are market competitive. Components analyzed for consideration in the price include facility charges, physician fees, ancillary services, lab, radiology, follow-up visits, PT/OT, etc.
Outsourced Managed Care Functions
For small, community-based providers, dealing with managed care related issues such as contract negotiations or claims denial management can be a complex, time consuming and daunting task. Hospital staff are rarely dedicated to devote full-time efforts on only this type of work.
KBH staff provides the expertise and resources to manage all managed care issues on behalf of hospital administration and can provide outsourced support on both short and long-term arrangements.
Selection & Training Managed Care Director & Staff
With administrative turnover a reality, let KBH assist in locating and training the right person for the job.
Expert Witnesses for Major Claims Disputes
KBH has served as an expert witness in several major legal claims disputes, providing technical support to legal counsel on behalf of providers. Utilizing our extensive data resources in combination with our managed healthcare experience, KBH assists in the dispute resolution process through detailed customized reports and depositions when necessary.
Our analysis and arguments analyze factors such as competitive pricing based on local and regional market factors, facility type comparisons, applicability of UCR pricing, and eligible payment variances.
PPO, PHO, Branded Product Development
KBH works with your providers to develop a vehicle that enables hospitals and physicians to work cooperatively toward mutually defined goals such as MCO contracting, development of protocols of care, and relationship building.
Our role as facilitator covers every aspect of the development from strategic feasibility to organizational and operational issues. While we are not able to provide legal advice, we work closely with your legal counsel to arrive at the proper structures which can meet the practical needs of the local provider community.