At A Glance
Revenue cycle teams need confidence that claims are being reimbursed according to contracts. See how improving their contract modeling strategy led to more accurate reimbursement analysis and better financial outcomes for Prevea Health.TABLE OF CONTENTS
Key takeaways:
- Revenue cycle teams need contract modeling tools that keep pace with changing reimbursement methods and payer rules.
- Returning to Experian Health’s Contract Manager and Contract Analysis gave Prevea Health greater confidence in its reimbursement analysis, helping staff identify underpayments earlier and investigate payment variances more efficiently.
- The changes delivered measurable results, including more than $323,000 recovered per quarter from key procedure codes, a 50% reduction in manual audit time, faster payments and fewer days in accounts receivable.
Challenge: Changing reimbursement rules put contract modeling to the test
Revenue cycle teams rely on accurate contract models to determine how much they should be paid for each claim and to confirm that payments match the agreed terms. Maintaining these models is increasingly challenging as organizations handle hundreds of agreements with different reimbursement methods and frequently changing payer rules.
Prevea Health experienced this firsthand. Processing up to 100,000 claims each month, the organization’s reimbursement analysis had become more demanding. The team needed more flexibility and visibility to help them model complex payment scenarios, simplify contract maintenance and calculate expected reimbursement with greater confidence.
“Our modeling needs grew more complex, and we needed clearer visibility into our results and greater certainty in the outputs. That’s when we recognized how much we had relied on the precision, flexibility and clarity of Contract Manager and Contract Analysis to have confidence in the accuracy of our numbers.”
Tony Walch, Revenue and Reimbursement Analyst at Prevea Health
Solution: Contract modeling designed for precision, flexibility and clarity
Prevea Health had successfully used Experian Health’s Contract Manager and Contract Analysis for many years before management changes prompted the organization to move contract performance work into Epic®. It soon became clear that those previous capabilities were needed again.
Returning to Contract Manager and Contract Analysis gave the team a more reliable way to compare expected and actual reimbursement, investigate payment variances and identify underpayments. Multiple payer contracts could be modeled in one place, and advanced reporting tools allowed staff to filter and analyze real claims data to understand the financial impact of new payer requirements. The team could drill down to individual procedure codes to understand how different payer contracts reimbursed similar services in different departments.
Implementation was structured to avoid interrupting the team’s day-to-day reimbursement analysis.
Maintaining contract models using this approach would also be less resource-intensive. Experian Health analysts updated the contract logic to reflect changes such as Medicare base years, Geographic Practice Cost Index (GPCI) updates and payer-specific reimbursement rules, helping improve accuracy without adding work for the team.
Outcome: Better reimbursement analysis pays off
Faster payments, fewer appeals and less time on follow-up
Contract Manager and Contract Analysis gave Prevea Health the precision, flexibility and clarity they were looking for. Earlier identification of underpayments meant recoveries could begin sooner, while fewer payment discrepancies reached the appeals stage. Staff spent less time on manual audits and follow-up, payments moved through the revenue cycle more quickly and days in accounts receivable fell. This translated into measurable operational and financial improvements.
| Key results: |
| – More than $323k recovered per quarter from key procedure codes |
| – 50% reduction in manual audit time |
| – Sustained improvement in payment variances |
| – Faster payments and fewer days in accounts receivable |
Better analysis leads to better decisions
For Walch, two capabilities made the biggest difference: a powerful modeling engine for testing different reimbursement scenarios and reporting tools that showed where revenue was being lost and where action was needed.
Variance monitoring highlighted payment discrepancies early, so issues could be resolved before they affected revenue.
“Even a small variance in modeling can have a significant impact,” said Walch. “Every undercharge we catch is revenue recovered and insight gained. It reflects how undercharge reporting revealed missed revenue, supported proactive corrections and improved long-term contract optimization, helping us stay ahead of issues rather than react to them.”
With greater confidence in their financial analysis, staff could apply the insights to other revenue cycle initiatives. This included charge master optimization and identifying claims reimbursed under “lesser of” payment rules.
Prevea Health’s renewed focus on accurate modeling and reimbursement visibility delivered clear operational and financial gains. Procedure code analysis became an ongoing tool for improving contract performance and budget planning. Undercharge reporting produced significant returns. Together, these tools continue to build a reliable foundation for greater financial decisions and better long-term performance.
Learn how Contract Manager and Contract Analysis, ranked #1 Best in KLAS for Contract Management, helps healthcare organizations strengthen reimbursement analysis, recover underpayments and improve financial performance.
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