Payer contracting and payer relationships can be difficult at best. However successfully navigating the challenges is key to maximizing revenue and volume. The payer landscape is evolving and many payers have entered the provider space with Specialty Pharmacy and Home Infusion Therapy offerings, not to mention PBMs and disease management programs that steer patients to payer owned or exclusive providers. Payer enrollment, credentialing and contracting is a significant barrier, however it does not need to be a brick wall. With the right resources, skills, strategies and processes, it can be much more like a speed bump.
Define and differentiate the terms enrollment, credentialing, and contracting within the payer participation process.
Describe and apply key negotiation components, including data analysis, contract language evaluation, rate assessment, strategic positioning, and decision-making criteria for accepting or declining an agreement.
Explain and implement post-contract best practices, including contract loading and validation, managing changes and updates, referral optimization, problem resolution, and building effective payer relationships.
