Provider-Owned Health Plans

As a provider-owned health plan one of your top priorities is building, maintaining and improving competitive posture within your market. Through the Coordination of Benefits process required for members with dual coverage, you’ve historically had access to a wealth of claims data, giving your contract negotiators the tools to truly understand the discounted contract rates that hospitals have negotiated with competition. But times are changing, and we know that you’re always aiming to improve your level of granular contract rate intelligence.

The Changing Landscape

Major changes in the health insurance landscape are underway, and fewer and fewer individuals have dual coverage. When it comes time to negotiate contracts with providers, you want more current and precise data to verify and supplement the intelligence gathered from COB and other high-level, third party data intelligence.

Similar to providers, you need to know how much room there is to negotiate more favorable contracts. Insurers with lesser market share normally pay higher reimbursement rates, and oftentimes, much higher rates than their competition. FlexPoint data helps you know the exact rate differences so that you’re not compelled to pay more than necessary.

No more guessing how your payment rates compare to your competitors, or whether you’re paying at, above, or below market.

No more guessing whether your contracts are fair, and whether you need to push for rate cuts or take a different approach.

Flexpoint Health gives you what you need to be able to set pricing and negotiate with confidence.

The Granularity You Need

Traditional consulting groups provide contract rate data that is calculated based on average payment rates within a market — and contract rate data that uses non-current blended public data or all-payor claims databases. Some provider-owned health plans make the critical mistake of relying on data provided in cost estimator tools made available by big insurance companies to their insured members.   These cost estimator tools share averaged pricing for only a limited number of services and fail to provide current, specific and meaningful rate information for specific providers in a local market. These types of data are only minimally useful when you are in negotiations or evaluating a new pricing strategy.

To gain better clarity, we believe that provider-owned health plans should have access to contract rate data that is at a level of specificity that matches the way contract rate sheets are written. Your organization deserves to have contract rate data that matches the way you and your competition reimburse providers for services. A health plan needs to know exactly what big insurers are paying hospitals in the local market. With a current and specific level of contract rate data, health plans can eliminate guessing and strengthen its ability to grow within the market.

We are able to deliver contract rate specificity for the services outlined in the table below.

SERVICE PRECISION OF CONTRACT RATE INTELLIGENCE
INPATIENT
Medical/Surgical DRG base rate; Per diem; % of charges
Carevouts (e.g. Maternity, Bariatric, Ortho, Psych, etc.) DRG base rate; Per diem; % of charges
Outliers % of charges & stop loss data
Implants % of charges & pass through data
OUTPATIENT
CT Fee schedule; % of charges; 3M – EAPG base rate if applicable
MRI Fee schedule; % of charges; 3M – EAPG base rate if applicable
Ambulatory sugery levels Fee schedule; % of charges; 3M – EAPG base rate if applicable
Emergency room levels Fee schedule; % of charges; 3M – EAPG base rate if applicable
Other outpatient Fee schedule; % of charges; 3M – EAPG base rate if applicable
Implants % of charges & pass through data