Managed Care Revenue Consulting Group

MCRC Group, is a highly skilled, accomplished team of health care professionals with over 50 years combined work experience with academic and community hospitals, physician practices, as well as large national and small regional health plans. MCRC Group excels in the areas of underpayment identification and revenue recovery, managed care contracting, negotiation strategy and contract compliance, and the implementation of gainsharing and other physician/hospital collaboration activities.

Managed Care Consultation on Contracting, Negotiation Strategy and Compliance

Over the last 20 years, the founders of MCRC Group have negotiated hundreds of managed care and other payor contracts on behalf of hospitals, ancillary providers, large physician faculty practices and small voluntary physician groups. On behalf of hospitals, they have implemented rigorous contract compliance programs to ensure that highly favorable contract terms were followed by the health plans. MCRC Group’s founders have managed various contract arrangements including full risk/capitated contracts, bundled fees, pay for performance, DRG, per diem and percent of charges, as well as negotiated comprehensive enhanced fee structures for small and large physician practices, ancillary providers and specialty groups. With exposure to payor arrangements around the country, MCRC Group maintains a confidential data base of best practice contract terms and can help you assess your market position and how to improve it.

MCRC Group can:

Review your current agreements for strengths and weaknesses, identify gaps in language or multiple/vague interpretations that might result in a payor’s inability or unwillingness to comply with YOUR intent of the term
Recommend specific changes to improve contract terms, enhancing revenue and protecting providers from denials and other issues
Assist in developing a strategy to successfully negotiate new agreements and implement a program to ensure contract compliance

Revenue Recovery

MCRC Group goes beyond where software is capable of going and performs a forensic analysis of claims data for each hospital service, for each payor, on a claim by claim basis, finding additional dollars due to your hospital or practice. The result is significant additional revenue to your bottom line. MCRC Group has collected over $40 million in additional revenue for hospitals on closed out zero balanced claims that were actually underpaid. On a go-forward basis, these efforts generated over $12 million annually in additional revenue due to system and contract corrections identified and fixed during the underpayment review and collection process. MCRC Group’s many years of experience on both the hospital and health plan side of the business in crafting managed care contract terms, understanding the limitations of payors’ systems, knowledge of conflicts and various interpretations of standard contract language, and working first hand with payors to correct system issues, uniquely qualifies MCRC Group to identify opportunities for greater revenue and collect the monies due to providers. MCRC Group investigates claims for all services, inpatient and outpatient, regardless of the level of expected reimbursement. MCRC Group has no limitation or threshold to pass in order to pursue underpayments - no variance is too small.

Gainsharing and Collaborative Initiatives

In 2006, the founders of MCRC Group implemented an inpatient shared savings/ pay for performance program at three New York City hospitals that rewarded physicians for reaching cost and quality benchmarks established by the hospitals on managed care patients. The hospitals quickly began to see physician behavior changes that resulted in substantial cost reductions and improvement in quality. In 2008, CMS awarded one of the hospitals with a waiver to perform the same ‘gainsharing’ program with fee for service Medicare patients, hoping to see similar results. The success of both the managed care and Medicare fee for service program at these hospitals led Greater New York Hospital Association to start an initiative to expand the program to more member hospitals, and CMS to recently solicit hospitals around the country to participate in similar demonstrations. MCRC Group now works with hospitals around the country to implement similar gainsharing and other hospital/physician collaboration programs that align the incentives of hospitals, physicians, and even payors. MCRC Group’s knowledge and experience in hospital operations, physician practice and payor processes, enables it to help many hospitals structure programs that motivate physicians to practice more efficiently and improve quality outcomes, yielding rewards for all involved.