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Effective contract management for healthcare organizations is pivotal in this complex and highly regulated world. Healthcare organizations, whether large hospitals, clinics, or individual practitioners, contract with various entities, including vendors, insurance providers, and regulatory bodies. These contracts govern everything from purchasing medical supplies to services reimbursement, making healthcare contract management a critical aspect of running a successful and compliant operation. What is healthcare contract management? Healthcare contract management is the systematic process of creating, negotiating, executing, monitoring, and optimizing contracts to ensure compliance, mitigate risks, and achieve healthcare organizations' strategic objectives. It encompasses various stages, including needs assessment, drafting, execution, and post-contract management. The importance of healthcare contract management for payers and providers Healthcare contract management ensures that healthcare organizations, including payers and providers, can efficiently navigate the contracts governing operations. For providers and healthcare contract managers, it's about ensuring their organization gets paid fairly for services while adhering to complex regulations. For payers, negotiating contracts with healthcare providers helps control costs while maintaining care quality. Tricia Ibrahim, Director of Product Management, Contract Manager Suite, states, “Better healthcare contract management directly impacts provider revenues. That's why many organizations implement healthcare contract management software. These tools help healthcare providers work smarter and get paid faster.” Challenges and opportunities in healthcare contract management The complex payer/provider landscape presents multifaceted challenges for organizations seeking to improve healthcare contract lifecycle management. The intricate web of regulatory requirements, privacy laws, provider-specific reimbursement structures, and shifting payment models adds complexity to contract management. Healthcare providers must navigate through contracts with various stakeholders, including suppliers, payers, and government agencies. Healthcare contract compliance with ever-evolving regulations is difficult in part because most providers manage these complexities manually. Providers seeking to improve healthcare contract management often turn to technology to help. OrthoTennessee, a multi-location orthopedic practice in Knoxville, Tennessee, with 164 providers, struggled with denied claims, smaller payouts, and a need for more contract management standardization. The organization used Experian Health's Contract Management tool to improve the accuracy of contract compliance. Today, this healthcare provider credits the software with helping the organization spot changes in payer rules and trends in how they pay. Experian Health's Contract Management platform drives significant efficiencies and time savings. It also provides critical data for payer negotiations. In 2022, OrthoTennessee had an 86% appeal success rate, thanks to more streamlined contract management. OrthoTennessee strongly advocates for Experian Health's Contract Management tool—and they've used it for over 16 years. Navigating the complex landscape of healthcare contract management The healthcare industry is notorious for its ever-evolving regulatory environment. Healthcare contract managers must stay up-to-date with these changes to ensure contracts remain compliant. Imagine doing this by hand when most healthcare providers deal with hundreds of different payers, each with its contracts, procedures, and paperwork. This lack of standardization slows down the claims process. With rising healthcare costs, payers and providers are under immense pressure to optimize contracts to maintain profitability while delivering quality care. As claims grow more complex and patient volumes rise, manual healthcare contract management becomes a bottleneck in getting paid. Healthcare organizations often operate in a highly competitive environment, making efficient contract management a strategic imperative. Failure to manage contracts effectively can result in lost revenue, operational inefficiencies, and strained relationships with key partners. Managing data-intensive healthcare contracts One of the most significant challenges in healthcare contract management is the data-intensive nature of these agreements. Payer/provider contracts contain vast amounts of critical information, such as billing codes and reimbursement rates. Managing this data accurately and securely is essential for compliance and successful operations. The sheer volume of contracts in healthcare organizations can be overwhelming, making it challenging to track, analyze, and report on their performance. Manual contract management processes are vulnerable to errors that can have significant financial and legal consequences. However, these challenges also present significant opportunities. The advent of technology, such as contract management software and artificial intelligence, has revolutionized the way healthcare organizations oversee contracts. These tools offer the potential to automate data extraction, analyze compliance, and streamline contract workflows, significantly enhancing efficiency and reducing the risk of errors. Frequently Asked Questions What does a healthcare contract manager do? A contract manager in healthcare is responsible for overseeing the entire contract lifecycle. Their duties include negotiating contract terms, ensuring legal compliance, monitoring performance, managing amendments and renewals, and fostering stakeholder collaboration. Contract managers play a vital role in optimizing contract efficiency and minimizing risks. What are the common types of contracts in healthcare? Provider Agreements: Contracts between healthcare providers (e.g., hospitals, clinics) and payers (e.g., insurance companies) that outline reimbursement rates and service delivery terms. Payer Contracts: Agreements between healthcare payers and providers that govern payment terms, coverage, and network participation. Pharmaceutical Agreements: Contracts between healthcare organizations and pharmaceutical companies for purchasing and distributing medications. Vendor Agreements: Contracts with vendors providing services, equipment, or supplies to healthcare organizations, ensuring quality and compliance. Better healthcare contract lifecycle management Healthcare contract lifecycle management is a comprehensive process encompassing all contract stages, from initial creation to final execution, performance monitoring, and eventual termination. This systematic approach helps organizations maximize efficiency, reduce risks, and ensure compliance with payer contract requirements. Understanding the contract lifecycle The lifecycle of an average contract has several phases. Work must be done at each step, and challenges arise even before contract signing. After signing, the healthcare contract manager must follow each payer's rules closely as they are subject to change. Pre-Contract Stage: Healthcare organizations must conduct a thorough needs assessment to define the agreement's scope before drafting a contract. This phase often involves communication with essential finance, legal, and operations stakeholders. The goal is to go into contract negotiation with a clear sense of organizational goals and where to draw the line. Payer Contract Formation: Successful contract formation involves negotiation and drafting that addresses all parties' unique needs and expectations. Key stakeholders must collaborate to ensure the contract meets legal and regulatory requirements. Standardized templates with clear, concise language minimize ambiguity and lessen legal risks. Execution of Contracts: To expedite contract execution, healthcare providers must establish approval workflows and methods for monitoring compliance after signing. This phase may include exchanging required documentation, such as insurance certificates or provider credentials. Notably, adopting e-signatures streamlines approvals, reducing common delays experienced with paper-based processes. Post-Contract Management Performance: After execution, healthcare organizations must actively and consistently monitor contract metrics against key performance indicators (KPIs). Providers must identify deviations from expected performance and address them quickly. Keep in mind healthcare contracts often require amendments and periodic renewals. Organizations must also have a standardized process for these changes and ways to manage new contract compliance workflows. How technology improves the contract lifecycle Technology plays a pivotal role in improving the entire healthcare contract lifecycle. From contract creation to execution, performance monitoring, and beyond, technology-driven solutions offer a range of benefits to enhance efficiency and improve compliance. Contract management software has revolutionized how organizations handle their contracts in the digital age. These specialized platforms offer a centralized repository for contracts, making them easily accessible and searchable. Critical features of contract management software include: Centralized Storage: Consolidates all contracts into a single, easily accessible database, eliminating the need for physical filing systems or scattered electronic documents. Automated Workflows: Reduces delays associated with manual routing and approvals. Electronic signatures further expedite contract execution. Version Control: Maintains a clear record of revisions, ensuring users consistently access the latest, up-to-date documents. Document Management: Aids collaboration, secure file storage, and document sharing. Alerts and Reminders: For contract milestones, such as changes, renewals, or termination dates, helping organizations stay on top of critical events. AI and automation in healthcare contract management AI can automatically extract essential contact data, helping organizations efficiently categorize, analyze, and report on their contract portfolio. Natural language processing and machine learning aid in contract risk assessment, compliance checks, and pinpointing critical clauses for review. Automation tools can generate contracts from standardized templates, reducing the time and effort required for contract authoring and negotiation. AI-driven contract review tools help legal and compliance teams identify deviations from standard language, flagging potential issues that need attention. Compliance checks and alerts can also be automated, ensuring that contracts meet changing regulatory requirements. Data analytics for contract oversight Data analytics for contract oversight is invaluable for overseeing contract performance and compliance. By employing data-driven insights, organizations can: Monitor KPIs to assess whether a contract is delivering the expected value. Detect anomalies, deviations from expected patterns, or changes in performance data to identify potential risks and compliance issues. Manage costs by analyzing financial data within contracts and identifying opportunities for cost reduction or resource optimization. Predict contract performance trends, helping organizations proactively address issues and make informed decisions. Ibrahim says, “There's a reason that Experian Health Contract Manager achieved Best in KLAS this year. The burden of proving a claim is underpaid or wrongly denied always rests with the provider. This software finally allows these organizations an opportunity to reduce the $157 billion annually lost on manual contract management.” Future of managing healthcare contracts The future of managing healthcare contracts will be transformational. Technology advancements will revolutionize the standard for healthcare contract lifecycle management. As technology advances, organizations that leverage these innovations stand to gain a significant competitive advantage in their revenue cycle. Some of the future innovations to expect include: Telehealth and Remote Contract Management: Telehealth will become integral to healthcare delivery. It will extend beyond traditional video consultations to include remote monitoring, diagnostics, and treatment plans and require a robust framework for contractual agreements between healthcare providers, insurers, and technology vendors. The expanding role of telehealth will necessitate innovative contract management solutions, leveraging technology and automation to ensure efficient, secure, and compliant remote contract management. Predictive Analytics and Machine Learning: These emerging technologies will reshape how healthcare providers manage contracts. Predictive analytics will enable organizations to anticipate contract performance trends, proactively identifying potential issues before they escalate. Machine learning algorithms can analyze vast amounts of contract data to uncover patterns and insights that may not be apparent through traditional methods. This predictive capability helps healthcare organizations optimize their contract management strategies, improve negotiation outcomes, and enhance overall operational efficiency. By leveraging these advanced technologies, healthcare providers can ensure compliance, reduce risks, and drive better financial and patient care outcomes. Empowering healthcare organizations for a successful future Ultimately, applying technology solutions to healthcare contract compliance and management empowers these organizations to succeed in delivering high-quality care. Healthcare is increasingly complex, and organizations must leverage technology, adopt best practices, and stay ahead of emerging trends. Experian Health's Contract Management solution allows providers to manage these complexities efficiently and improve their revenue cycle. Contact us to learn how our Healthcare Contract Management software can help your organization validate reimbursement accuracy, recover underpayments and more.

Millions of healthcare claims are denied annually, costing providers billions in lost revenue and expensive appeals. A 2024 survey shows that around 15% of all claims submitted to private payers, Medicare Advantage and Medicaid managed care plans are initially denied. Since most involve charges of $14,000 and above, the stakes are worryingly high. Frustratingly, more than half of these denials are eventually overturned, but not before providers have spent an average of $43.84 reworking each claim. With hospitals and health systems spending almost $20 billion on denial management in 2022 alone, this administrative tug-of-war with payers brings a substantial toll. While some denied claims are valid, there's no doubt that many are avoidable, as evidenced by the number that are successful on the second try. This is where effective claim denial management strategies and solutions come into play. Understanding the root cause of denials in healthcare and implementing the right systems ensures that claims are right the first time. This article looks at the importance of denial management, strategies for improvement, and why more providers are shifting from defense to offense by putting automation and artificial intelligence (AI) at the heart of their claims management processes. The importance of denial management in healthcare A traditional denial management definition in healthcare might focus on the steps needed to resolve denials after they occur. The reality is much broader. Providers need a proactive strategy that addresses why claims are denied in the first place to prevent them from occurring in the future. Claims may be denied because the insurer doesn't consider the treatment medically necessary, believes there's a cheaper alternative available or doesn't cover it because the patient's insurance doesn't cover it. Sometimes, the culprit is an erroneous billing code or typo. Providers avoid costly and time-consuming rework by ensuring that claims are accurate, compliant, and complete at the start. As denials become more common and costly, streamlining denial management is increasingly urgent. The provider-payer relationship One of the major challenges for providers is the shifting relationship with payers. According to a survey by the American Hospital Association (AHA), 78% of hospitals say interactions with commercial payers are getting worse, with 84% noting the rising costs of complying with insurer policies. Providers report spending more time on prior authorizations, yet the growing pile of denials includes pre-authorized services. The pattern of claims being denied and then granted on appeal drains financial resources, delays patient care and contributes to staff burnout. Moreover, payers have been much faster in adopting AI-based technology, allowing them to process and deny claims at an unprecedented rate. Providers that rely on traditional denial management methods are starting to fall behind. The denial management process: how it works Healthcare denial management involves four key steps: Track all claims from submission through final adjudication and identify denials as quickly as possible. Denials should be categorized by type, payer and service to identify trends and understand underlying issues that need addressing. Investigate the cause of each denied claim, such as coding errors, missing documentation or non-adherence to payer guidelines. This stage often involves collaboration among billing teams, coders and clinicians to pinpoint what went wrong. Rework the claim by gathering missing data or documents and correcting errors before resubmitting the claim to the payer for reconsideration. This will also include monitoring the outcome to see if the appeal is successful. Prevent future denials through improvement measures such as staff training, updates to billing software, and ongoing payer policy reviews. A preventive approach ensures claims are managed without a hitch and keeps revenue flowing. Strategies for effective healthcare denial management Prevent denials upstream with accurate patient access Because so many denials originate early in the revenue cycle, patient access should be the first target in any denial reduction strategy. Experian Health's Patient Access Curator solution uses AI-powered data capture technology to collect and verify patient information in seconds. A single click checks eligibility verification, coordination of benefits (COB), Medicare Beneficiary Identifiers (MBI), coverage discovery and financial information to determine the patient's propensity to pay quickly and accurately. Staff no longer need to run multiple queries and can have confidence that their claims are built on the correct data. Watch the webinar to learn how Patient Access Curator shifts denial management upstream and propagates clean data throughout the revenue cycle. Process denials more efficiently with workflow automation A second strategy is to automate the denials workflow to alleviate the administrative burden on staff and expedite the appeals process. Denial Workflow Manager automatically identifies denials, holds, suspends, zero pays and appeal status so staff can follow up quickly, without the need for manual reviews. They'll have the time and intel to rework the denials that are most likely to be overturned, resulting in maximum cash flow. When used alongside ClaimSource®, they can do all this using standardized protocols with claim and denial information on the same screen. Denial Workflow Manager provides American National Standards Institute (ANSI) reason and payer codes and descriptions so staff know precisely why a claim was denied. Reports and responses can be forwarded to Health Information and Practice Management Systems to facilitate better coordination. The tool also provides advanced analytics to identify trends and inform tactics for further improvement. This significantly reduces the overall time and cost associated with managing denials. The future of denial management in healthcare While automation has lifted healthcare denial management out of inefficient manual processes, AI takes predicting and preventing denials a step further. AI AdvantageTM enhances the denial management toolkit with two new offerings: Predictive Denials uses the provider's own claims data from within ClaimSource to identify claims that are most likely to be denied, so staff can step in to take corrective action before submitting the claim. Denial Triage analyses and segments denials that do occur so staff can focus on reworking claims with the highest potential for reimbursement. With these tools, providers can eliminate guesswork, reduce denials and minimize financial losses. But it's not just about finding more innovative ways of working: payers have already made huge strides in using AI to deny claims at speed and scale. The future of denial management in healthcare will hinge on technology, and providers will need to adapt to keep up with the fierce competition. Find out more about Experian Health's Denial Management Solutions and see why they're top-rated by clients in the 2024 Black BookTM RCM User Survey. Denial Management Solutions Contact us

Could healthcare organizations be doing more to open their digital front door? According to a 2024 study by HIMSS researchers, hospitals that embrace digital technology see stronger patient experience outcomes. This aligns with Experian Health's most recent State of Patient Access (SOPA) survey, in which patients and providers agreed that patient access had improved thanks to digital technology. Adoption of digital health technology accelerated in response to COVID-19, as healthcare organizations sought to manage demand and facilitate “contactless” access to care. Telehealth, mobile apps and patient portals gave patients more control over their health while allowing providers to deliver more personalized and efficient care. With over half of healthcare providers and nearly a third of patients acknowledging improvements in access since before the pandemic, it's clear that offering more digital options is a powerful strategy to improve patient engagement and streamline access. Progress is encouraging, but there are always opportunities to do more. What is healthcare's digital front door? Healthcare's “digital front door” includes all the digital channels through which patients access care, such as websites, patient portals, mobile registration and payment apps, telehealth platforms and online scheduling tools. The goals are to create convenient and user-friendly entry points for patients to engage with their providers, use online tools to expand access, improve patient satisfaction, and increase operational efficiency. Why a digital front door is crucial for healthcare providers When asked why they believe patient access has improved since before the pandemic, the top four reasons given by patients all relate to scheduling and registration processes: Being able to see a doctor quickly (72% agreed) Checking in and registration (61% agreed) Scheduling appointments (58% agreed) Finding appointments that work with their schedule (57% agreed). In other words, patient access improves when providers open the digital front door. Alex Harwitz, VP, Digital Front Door, at Experian Health, explains that for providers, this equates to two major benefits: 1. Improves patient engagement Harwitz says that putting access in the hands of patients gives patients more flexibility and choice about how and when they book appointments, fill out registration forms and pay for care. “There's a growing demand for easy, accessible healthcare, and opening the digital front door is how we meet it. Digital tools use automation and data analytics to create a more personalized and convenient patient experience, making it easier for patients to remember appointments, adhere to treatment plans and manage their financial obligations,” he says. “That's huge for busy households. The to-do list just got a lot shorter, so it's easier for them to engage.” 2. Streamlines patient access A second key benefit is reducing friction and bloat in patient access workflows. Harwitz says, “By expanding their online offerings, providers not only make it easier for patients to see their doctor sooner, but they also reduce demand on front office staff. Self-service options, performance reporting and data insights allow providers to allocate resources more effectively. It’s about making sure everyone gets the right support at the right time, whether that's online or in the office.” Getting the patient journey off on a strong footing also pays dividends throughout the rest of the revenue cycle: with fewer errors and faster throughput, collections and claims management improve, too. Read more: How patient access technology is transforming the healthcare revenue cycle Key components of a digital front door As more providers offer online patient access, competition for the digital front door is increasing. With 60% of patients looking for more digital and mobile options to meet with providers, schedule appointments, and manage bills and payments, these would be smart areas to prioritize for a competitive advantage. Here's what that might look like: 1. Cut paperwork and calls with self-service scheduling and mobile registration It should come as no surprise that a vast majority of patients say they do not like repetitive paperwork. Online and mobile-enabled scheduling and registration reduce form-filling and lengthy calls. For example, Patient Schedule gives patients a platform to book, cancel and reschedule appointments with ease, anytime and anywhere. Appointments are matched to patients' needs so no slots are wasted and patients see their doctor sooner. Mobile registration increases bookings further. With Registration Accelerator, patients receive a text that prompts them to scan their identity and insurance cards, so they don't need to wait in line to fill out forms. Validating their data from the start also improves billing accuracy and reduces the risk of downstream denials. 2. Make it easier to pay for care Simplifying the financial experience is a major component in opening the digital front door. Patients are worried about the cost of care and say that having accurate price estimates before treatment helps them plan for bills. With Patient Payment Estimates, providers can give patients accurate, upfront estimates of their out-of-pocket costs, while tools like Patient Financial Clearance can help direct them to appropriate payment plans. It's also important to make the actual payment process as straightforward as possible. Accepting payments 24/7 from any device allows patients to pay promptly and helps providers avoid bad debt. Checklist: 5 patient-friendly billing practices to accelerate collections 3. Communicate clearly for a great first impression At its core, opening the digital front door is about creating a welcoming first impression for patients. Patients don't want confusing instructions or radio silence when they have questions. They want proactive, helpful and clear communications. One of the benefits of digital tools is having the data and automation capabilities to send patients timely and personalized messages and reminders using their preferred channels. They can also drive targeted outreach campaigns using text messages and interactive voice responses to encourage patients to book appointments and make payments. The future of healthcare's digital front door These are just a few examples of how providers can expand their digital offerings to make it easier for patients to access care. But what will the digital welcome mat look like in the future? Advances in artificial intelligence, digital apps and wearable tech will transform the way patients interact with their providers. Hockey-stick growth in data generation will make data security and interoperability non-negotiable. It's a big ask of providers. Partnering with an expert third-party vendor will help digitally forward organizations remain responsive and adaptable. Find out more about how Experian Health helps providers open their digital front door with mobile scheduling, registration and payments.