Our mission is to enhance our clients' managed care reimbursement. Our goal is to closely align our incentive with our clients', often, a portion of our fees are at-risk. We combine an innovative approach with experience and a commitment to results...our clients' advantage, maximized reimbursement.
Case Study - Urban Health System
Assignment:
The Managed Care Contracting Division of Carlisle and Associates was retained by a financially strained multi-hospital healthcare system, serving an urban population. The hospitals, which make up the system, had been unsuccessful in their attempts to bring one of their largest commercial insurance payors, with which they had expired contracts, to the negotiating table for over one year. Upon executing a Letter of Engagement, Carlisle's Contracting Team assumed responsibility for the negotiations of a new replacement contract with enhanced HMO and PPO reimbursement rates on behalf of the health system. Throughout the course of the assignment, the negotiators' challenge to increase reimbursement was complicated by an ongoing "underpayment" lawsuit and a "take-back" dispute damaging the provider / payor relationship.
Underscoring Carlisle and Associates' commitment to maintain aligned incentives with its client, Carlisle assumed a contingency-based fee structure - the firm's fees were directly linked to its ability to increase its client’s reimbursement rates and gross revenues.
Client Profile
The healthcare system is one of the largest providers of health care to a densely populated urban center and its surrounding communities. Its hospitals provide a comprehensive range of services - from primary and emergency care, to such specialized services as minimally invasive cardiac surgery, state-of-the-art cancer care, mental health care, HIV research and rapid testing, and breast cancer screening and treatment.
Contract Delivered:
Carlisle's Manage Care Contracting Division was not only successful in bringing the payor to the negotiating table, the health system's leadership executed a multi-year replacement provider agreement, as well as a letter of addendum, which fully resolved both the underpayment lawsuit and "take-back" dispute. The result was both dramatic double-digit revenue gains and several million dollars in net savings.
The contract delivered was a measurable and tangible increase over previously agreed to reimbursement rates. The replacement agreement contains rate increases that are dramatically above Medical CPI, in every year of the contract’s term. The current contract is a direct result of Carlisle's efforts on behalf of its client. During the negotiations Carlisle and Associates assigned an industry recognized contracting expert, with 20 plus years of senior level commercial insurance payor experience, to advance the process to the client's benefit.
Conclusion:
Carlisle's Managed Care Contracting Division partnered with a besieged health care system that was financially hemorrhaging, to negotiate a new replacement provider agreement opposite a hostile commercial insurance payor. Carlisle’s team represented the health system from the initiation of the negotiations through receipt of an executed contract and addendum. The enhanced reimbursement and the payment settlements have increased the health system's viability and have had the effect of improving the payor / provider relationship going forward.