Managed care payor integrity encompasses the processes and activities that oversee contracts between the UTMB health system, its provider network, and payors (including insurance companies, HMOs, and government programs like Medicare and Medicaid). These contracts define the terms for reimbursement of services provided to insured patients. Payor integrity ensures that claims are paid accurately, contract terms are honored, and both overpayments and underpayments are identified and corrected.
Contract Compliance and Monitoring
- Monitor adherence to agreed-upon terms.
- Ensure payors fulfil obligations, such as timely payments and correct reimbursement rates.
- Track claims and payments to verify proper reimbursement for services rendered.
Claims Management
- Ensure claims are processed efficiently and according to contract specifications.
- Address issues such as coding errors, duplicate claims, and incorrect benefit coordination
Reimbursement Dispute Resolution
- Address discrepancies between actual reimbursement and contractually agreed amounts.
- Facilitate and support negotiations and corrective actions with payors.
Contract Competitiveness
- Periodically review contracts to ensure they remain competitive and reflect current market conditions.
Data and Reporting
- Track financial performance metrics related to contracts (e.g., payment turnaround time, denial rates, contract compliance).
- Produce regular reports on key performance indicators (KPIs) to inform strategic decision-making.
- Use analytics to identify trends and areas for improvement.
Payment Risk Management
- Identify and mitigating risks associated with contract terms, such as reimbursement shortfalls or changes in payor policies.
- Manage potential impacts of unfavorable contract terms on financial and operational stability.
- Communicating contract changes or updates to all stakeholders within the organization.
Audit and Reconciliation
- Conduct internal audits to assess payment accuracy and appropriateness relative to contractual terms.
- Reconcile contract terms with actual payments received and make necessary adjustments.
- Use both pre-payment and post-payment reviews to ensure integrity throughout the claim lifecycle.
Travis Crum, MBA
Director of Payor Analytics and Integrity
Phone:
409-747-1171
Email:
twcrum@utmb.edu
Candace Varela
Senior Revenue Integrity Analyst
Phone:
409-772-0808
Email:
clvarela@utmb.edu
Sylvia Palomo
Senior Revenue Integrity Analyst
Email:
sypalomo@utmb.edu