"RealRate™: Transform Your Medical Practice with Superior Negotiation Power
In July 2022, the Centers for Medicare & Medicaid Services (CMS) continued its push towards increasing price transparency in healthcare. An extension of the Transparency in Coverage Rule originally finalized in October 2020–the one requiring most group health plans and health insurance issuers to disclose price and cost-sharing information–this new mandate increased transparency requirements to an unprecedented level.
“To say that the new mandate sent shockwaves through the healthcare industry is an understatement,” says Adam Middleton, principal at The Viability Company, a Nashville, TN-based organization that oversees managed care contractual relationships. “It was like a major earthquake, and it completely changed the pricing landscape.”
In the simplest terms, the rule mandates that health plans and insurers must provide detailed pricing information–including negotiated rates with in-network providers, historical payments to out-of-network providers, and the cost of prescription drugs–in an accessible format. Part of a broader trend towards consumer-centered healthcare, the regulatory change has empowered providers to make informed decisions as they contract with payers.
How does the July 2022 regulatory change impact provider negotiations with payers?
Although it’s not the first initiative mandating that healthcare pricing data be made public, the July 2022 CMS regulatory change extended the depth and breadth of data required–and that benefits both providers and payers. Transparency data levels the playing field for providers and payers, allowing both parties to reach a fair and acceptable agreement.
Where does all the data come from and how often is it updated?
Per the 2022 CMS regulatory change, it is the payers’ responsibility to publish detailed pricing information–including negotiated rates with in-network providers, historical payments to out-of-network providers, and the cost of prescription drugs–on a monthly basis.
What does the data look like?
One of the requirements of the 2022 CMS regulatory change is that the pricing data be published in an accessible way. Keep in mind, however, “accessible” is a relative term. While this level of detail and the frequency of updates were designed to enhance transparency, encourage competitive pricing, and ultimately drive down healthcare costs by empowering consumers and other stakeholders, it has also created a ton of raw data to sift through. “Between dozens of major insurers, hundreds of smaller insurance companies and health plans, and numerous government programs, there is a tsunami of data out there,” says Middleton. “And raw data is very noisy. Not to mention, the sheer volume of it every single month can quickly create confusion and a real obstacle to consuming it in a useful or timely manner.”
What good is all of that data if I don’t have an easy way to make sense of it all?
You’re right. Raw data can’t answer questions specific to you and your market. The good news is, we have a solution. At The Viability Company, we use a proprietary, full-service analytics platform called RealRateTM that not only analyzes all of the public data in any given market but also interprets that data in a meaningful, actionable way. “The interpretation piece is a total gamechanger,” says Middleton. “There are plenty of payers out there who can tell you what the rates are, but we go further. We combine that information with our team’s depth of healthcare experience and turn it into a competitive advantage for healthcare providers.”
How does RealRateTM work?
It’s simple, really. All we need from you is a list of payers and providers, and RealRateTM does the rest. We can source as much data as you need or want, from a targeted search on local competitors to a full national scope. Our data analysis team then organizes the detailed market intelligence into easy-to-understand, actionable data visualizations that help you quickly identify your strengths and weaknesses.
How can RealRateTM help me gain an advantage in my market?
RealRateTM is able to quickly analyze a nationwide dataset covering over 165 health plans and more than 350 networks in order to:
● Benchmark reimbursements against your competitors
● Develop pricing strategies
● Evaluate new market opportunities
● Accelerate decision making
● Monitor ongoing changes
● Improve contracting outcomes
You get the benefit of customized insights built according to your specifications–all with one-click web access.
“RealRateTM takes the guesswork out of negotiating with payers,” says Middleton. “It’s the difference between blindly asking payers for money versus presenting them with an informed and intelligent proposal.”
What role does RealRateTM play in managed care strategy development?
“As rates have become almost retail-ized, RealRateTM is absolutely paramount at contract negotiation time,” says Middleton. “Think of it like Zillow for your rates. It’s a real-time snapshot of exactly what’s going on price-wise in a market.”
The results are pretty powerful. For instance, we helped one of our single specialty practice management company clients achieve 100% medicare reimbursement on Managed Medicare Plans from a starting point well below current CMS rates. We were also able to increase their commercial payer reimbursement by 25% with one national payer. “We didn’t know how much we were leaving on the table before,” says the COO.
The truth is, it’s a win-win all around. Having that data contributes to better agreements, fosters a mutual understanding between payers and providers, promotes efficiency, and ultimately enhances the overall quality of healthcare services.
Can RealRateTM help me to plan and forecast revenue?
Yes–and the interface is easy to use and understand.
RealRateTM allows you to:
● Quickly model your revenue, select a fee schedule for rates, and upload your procedure volume
● Forecast what your reimbursement may look like with a peer’s fee schedule in place
● Evaluate the potential benefit of carving out specific rates
● Drill down to individual CPT/DRG codes to see where you may be able to make up ground
Can RealRateTM help me evaluate and plan for line of business (LOB) growth?
Yes, in two simple steps on the user interface, RealRateTM can provide insight into how profitable specific LOBs are in your market:
Input new service areas to see peer fee schedule details for payers you already have a relationship with.
See which specialty Viability recommends based on your peer providers and their fee schedules.
Our clients say the insight is invaluable. “Whenever we’re looking at a new market or adding a new service to our medical facilities, we turn to RealRateTM and Viability,” says the CEO of one of our practice management clients. “They are such a solid resource and always help us find the right solution and ensure we’re getting the best deal possible without negative impact to our overhead especially in this post-pandemic recession.”
What else does The Viability Company do?
We know you’re always navigating competing priorities and heavy workloads. At The Viability Company, we combine the power of RealRateTM with over 25 years of healthcare expertise to operate as an extension of your business. Our deep network of healthcare experts include specialists in credentialing, sanctions monitoring, roster management, denial prevention, and more to provide key operational support for your payer contracts and revenue cycle.
Really, our job is to make yours easier. Schedule a call today.