Gain the Upper Hand in Competitive Pricing and Payer Negotiations

Gain the Upper Hand in Competitive Pricing and Payer Negotiations

A Look Behind the Curtain at Stratasan’s APCD Payment by CPT Code Report

By Becca Groner

For many hospitals, competitor payment information can be complex to decipher due to a lack of access to clear, aggregated payment data. Because of this, many of our partners lack the insight they need to effectively navigate preferred payer negotiations and service line expansion efforts. Often, teams don’t have access to actual reimbursements beyond Medicare and EMR data. This means they don’t have the critical intelligence they need, which can be derived from all-payer claims data (APCD).

In this post, we’ll discuss why hospitals need a better solution, why APCD provides helpful insight, and what steps strategic planners can take to access this critical intelligence.



Why You Need a Data-Based Solution

The decision to work with a new payer or renegotiate with a current payer is a high-impact, important choice for a hospital and their patient population. A payer change could cause patients to transfer to another provider for care if their payer will no longer cover care at your facility. Alternatively, it could also work in your favor, as it could lead to new patients because you do offer a certain provider.

Another serious concern for hospitals is that payers often have the upper hand in these negotiations. This is true for several reasons:

  • Payers can use hospital claims data to determine how they will reimburse a hospital for their services and assess the value they provide to their patients.
  • Payers have greater buying power due to their control over where patients, or “consumers” will go for care.
  • Managed care teams have to properly win over a payer to work together but they also have to ensure they will receive fair reimbursement rates for their procedures and that physicians in their network won’t leave with the introduction of a new payer and potentially dropping coverage under an existing payer.

For hospitals to gain an advantage, they must have access to reliable, transparent data that can improve their bargaining power.


Why Medicare Isn’t Enough and How APCD Can Help

With the 2019 CMS regulation to make charge data public on hospital websites, hospital planners have a starting point from which to look at how competitor hospitals bill for various procedures. Billing data gives a slice of the payment picture but it’s not enough to help planners see the full payment picture. APCD is needed for more complete insights. APCD unlocks data on charges and payments together, which is the critical insight that planners need.


Stratasan’s All-Payer Claims Payment by CPT Code Canvas Report

Stratasan’s APCD Payment by CPT Code report provides strategic planners with critical intelligence for service pricing and payer negotiations. In developing this report, our team analyzed all-payer claims data for findings within remit claims and talked to users about their pain points when it comes to discovering payment trends. We set out to solve for the following two use cases for remit claims data:

  • Competitor data: When hospitals look at payment data, they need to see the average billed and paid amounts for procedures (based on CPT code) and how payments differ by facility and payer. This intelligence is critical for service line expansion efforts and is especially helpful when comparing how the competition is charged and paid for the same CPT codes.
  • Payment negotiations: When hospitals look at competitor data, they need to see how facilities, clinics, and provider groups are being paid differently for the same CPT and which payers they work with, so they can understand payments in their market and negotiate payer contracts.

Using remit data from APCD, this report provides the necessary insights to grow a service line profitably and negotiate confidently. It includes the following features:

  • Access to both average charge and average payment information at the CPT code level with facility names
  • Ability to define a service area at the facility ZIP-level
  • Ability to define custom product lines using CPTs
  • Claim type to distinguish institutional claims from professional claims
  • Exact payer plans associated with facilities in a market
  • Ability to filter to exact CPT codes, payers or facilities


Leveraging All-Payer Claims Data

To help facilities understand how they are reimbursed for various procedures, strategic planners need to be able to pair charge data with payment data. Our APCD Payment by CPT Code report utilizes our APCD to uncover payer trends at a more granular level, allowing strategic planning and managed care teams to explore payment data and charge data side by side.


The Takeaway

Stratasan’s APCD Payment by CPT Code report provides the opportunity for improved market benchmarking, business development, and payer negotiations. Armed with this all-payer claims data-based intelligence, hospitals will be equipped to plan and negotiate with confidence. For more information about how to use and benefit from our APCD Payment by CPT Code report, schedule a discovery call with one of our experts today.

Article by Becca Groner, Product Manager for Stratasan

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