Traditional fee-for-service reimbursement is contributing to higher healthcare cost trends. As the healthcare landscape changes, provider reimbursement is increasingly moving toward being risk-based. The effects of this are far reaching, affecting provider reimbursement from federal, state, and private payers for commercial, Medicare, and Medicaid populations.
Understanding your risk-based contracts is critical to ongoing success. Many contracts include an element of downside risk. If your organization doesn’t understand the contract terms and doesn’t negotiate the appropriate contracts, you could be at risk for significant losses. Even in upside-only contracts, it is important to fully understand your contract in order to maximize opportunities.
Milliman can help you evaluate and mitigate the insurance risks so you can increase your chances of financial success. The profitability of risk-based contracts is heavily dependent on actuarial parameters, such as setting the target, comparison group, risk adjustment, projection factors, stop-loss limits, and attribution.
The new world of risk contracting has many subtleties and nuances. A given term may have multiple meanings in different contracts. We can help you understand exactly what the term means in the context of the specific contract and how it affects financial risk, care delivery, and more.