Commercial Rate Analysis

Building a Foundation for Fair Reimbursement

As part of the Kansas Rural Health Transformation Plan, PYA, PC, a national healthcare consultancy, will perform a statewide rural commercial rate analysis. The result will be a more data driven view of commercial reimbursement as compared to Medicare reimbursement (reimbursement yield on paid claims) across rural Kansas.

Replacing Anecdote with Evidence

Payer rate discussions for rural healthcare providers today rely largely on anecdotal reporting. With a complete statewide analysis in hand, providers will be well-positioned to negotiate together for  fair reimbursement to sustain services in the community.

There is significant interest throughout the state in pursuing joint contract negotiations through clinically integrated networks. This rate analysis will provide a foundation on which those efforts can move forward.

Provider Engagement

To perform the analysis, the consultant will need each provider to produce two years of closed claim data files. Assistance will be available to help providers extract data from their EHRs. PYA will not disclose any provider’s identified data to any third party  without express written permission.

How the Analysis is Performed

Key steps in the work include the following:

• Analyze actual reimbursement data on closed claim data files, for each rural provider to understand how commercial payers are reimbursing hospitals today.
• Benchmark commercial reimbursement for key payers against Medicare allowable cost and reimbursement, by provider for top payers.
• Review available financial information for rural providers to identify those that are at risk and may require additional consideration.

A Stronger Positoin at the Table

The completed analysis will give rural providers a defensible, data-driven basis for payer negotiations and will help employers evaluate the performance of commercial payers.  .

For questions regarding the statewide rural commercial rate analysis, please contact Martie Ross at mross10@kumc.edu.