Contract Management


Gain visibility into claim payment logistics by modeling commercial and government contracts

Contract Engine


Valetude's contract engine has been proven in over 150 hospitals nationwide for managed care, Medicaid and Medicare for primary and secondary payers. Expected payment calculations can be used to appeal underpayment variances and denials, or to prioritize charge capture and coding initiatives. Results are linked to our RCI Engine and can be used to build work queues.

Analytics


  • Report frequency of different contract lines being triggered
  • Review fee schedule rates across all payers for a single CPT/HCPCS
  • Review all claims that have been assigned a contract and do not calculate an expected value
  • Identify claims that have hit the Max Pay Stoploss or that have charges close to the Threshold Stoploss (to be used for potential Pricing and Charge Capture opportunity)
  • Isolate and measure lesser of charge/rate instances
  • Measure and report gross to net % return

Performance and Interaction


Valetude's contract modeling solution is optimized to process hundreds of patient calculations per minute. The platform is streamlined for efficient interaction, allowing last year's contracts to be copied to the current year and insurance plans to be easily mapped to contracts. Use modern web based tools to bulk upload fee schedules in seconds.

Utilizing these features, our clients are able to quickly update and reprocess retroactive changes. For convenience, Medicare tables are imported directly from a CMS system.

Broad, Flexible Contract Term Coverage


Valetude software supports all standard contract providers and rule types, and provides mechanisms for constructing custom logic where necessary.

Providers

  • Managed Care/Commercial
  • Medicaid
  • Medicare
  • Primary and Secondary Payer

Rule Types

  • Case Rates
  • Groupers
  • Add-Ons
  • Fee Schedules
  • Carve Outs
  • Case Stop Loss
  • Custom

Calculations

  • MS/APR DRG
  • Fee Schedule
  • Lesser of Payment Variations
  • % of Charge
  • Per Diem
  • Per Service Unit/Day
  • Custom

Special Features

  • Tiered Pricing
  • Packaged Fee Schedules
  • Inpatient and Outpatient Stop Loss Logic
  • Min Max Charge, LOS, Code Specific and Age Thresholds

Strategic Contract Modeling: How it Works


  1. Load model contracts by copying existing contracts and changing proposed rates/terms
  2. Create a baseline claim to be used when modeling new expected calculations
  3. Add additional model claim parameters prior to calculating the model expected value, including:
    • Inflation Rates
    • Alternate Charge Master
    • Alternate Coding and CPT/HCPCS Modifications
  4. Compare the performance of hypothetical contract versions to each other using actual patient data
  5. Benchmark contract performance against MCR or another managed care contract