Payer Strategy Solutions
Experts in Payer Strategies
Partnering with medical labs, managed care companies, health systems, and providers, we offer subject matter expertise and insights into in-network credentialing and contracting, strategic planning, managed care contracting, and value-based care contracting.
Why Payer Strategy Solutions?
Lighthouse Lab Services has a history of delivering results that can be counted on.
A provider term that generally represents the process of a provider applying to health insurance companies/payers for participation in their networks. Payer network types include HMO, PPO, POS, EPO, Medicare Advantage, Medicaid, and rental networks, to name a few.
A payer term that generally represents the internal process of reviewing a provider’s credentials against national, standardized protocols and standards, such as those presented by NCQA and URAC. Payers utilize credentialing committees that meet with varying frequencies and are the critical dependency to contracting.
This step occurs following successful credentialing. Once a provider is credentialed, a standard network contract is offered to the provider. Typical reimbursement rates are based upon a fee schedule as a percentage of Medicare.
What is Medicare Advantage?
Medicare Advantage is a Medicare health insurance plan offered by a private-sector health insurance company. Medicare Advantage health insurance companies offer HMO and PPO products and networks.
Why can some labs not get in-network?
Health insurance companies manage their provider networks in a variety of ways and under different strategies. For example, HMO networks tend to be more limited in the number of providers in-network due to restrictive contracts and network leveraging. PPO networks, on the other hand, typically offer more member and provider choice of which labs to utilize. Some payers simply use a network need criteria standard, while some require the lab to be located within their state or service area. These are just some of the requirements that may restrict a lab’s participation in network.
Can you re-negotiate your contract?
Many first-year contracts are standard network contracts with non-negotiable contract language and reimbursement. However, there may be exceptions based upon unique or complex services provided. Once a lab establishes a solid track record of quality and excellent turnaround times with little to no provider and/or member complaints, it will be in a better position to renegotiate its contract.