Health reform likely to shake up your private payer relationships

Why This Topic Matters

Changes in payer behavior can affect contracting, reimbursement workflows, utilization oversight, and administrative operations. Understanding these trends helps practices prepare for evolving private payer expectations and related revenue cycle impacts.

Article Sections

1. Expected changes in provider-payer relationships

   Introduces how health reform is expected to alter dealings between providers and private payers. Frames the article around broad operational and contractual changes.

2. Anticipated shifts in payer mix and managed care

   Describes how coverage expansion may affect patient volume and how some coverage populations may move between plan types. Focuses on broader market changes rather than specific payment policies.

3. Greater medical management and scrutiny

   Covers increased payer oversight of treatment decisions and claims activity. Discusses how reform-related pressures may influence payer behavior.

4. Changes in payment structures and administrative delegation

   Summarizes how payment arrangements and delegated functions between payers and provider organizations may evolve. Includes discussion of integrated care arrangements and administrative services.

5. Network design, quality, and provider-payer interdependence

   Explains how payers may use network design and quality measures to compete in the marketplace. Also addresses the growing mutual reliance between payers and providers.

6. Claims processing

   Notes expected efforts to standardize claims processing and improve administrative efficiency. Focuses on general workflow effects for claims handling.