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?
Founded by seasoned and experienced healthcare executives with a combined 40 years in the industry, the Payer Strategy Solutions team offers a wide range of managed care consulting services. Whether developing go-to-market strategies, advising clients on the current state of the managed care industry, or negotiating payer contracts at favorable pricing, we work collaboratively and professionally.
Review our latest case study on how we helped one of our clients get 18 contracts, which include a combination of Medicaid, MCOs, and Blue Cross Blue Shield (BCBS).
Lighthouse Lab Services has a history of delivering results that can be counted on.
Service Terminology
Enrollment
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.
Credentialing
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.
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.
The Payer Strategy Solutions team also provides reimbursement analysis and assistance with pre-authorizations and interpreting medical policies. With 40 years of industry experience, we have the contacts and ability to generate more revenue for our clients.
Service Highlights
Through In-Network Agreements, We Enable Our Clients To:
Increase patient and specimen volume
Build successful relationships with payers
Grow market share
Improve reimbursement
FAQs
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.