Case Study

Dialysis Contracting Strategy, Education, Reimbursement Modeling and Workplan

Giandana Healthcare Consulting assisted in updating and streamlining a payer organization’s current network dialysis provider agreements. The client ‘s goal was to adopt the industry standard rate model while expanding regional rates to include out-of-area centers which are owned and operated by the regional/national dialysis chains.

The firm proposed a rate structure model consistent with other health plans across the US. Expanding the reimbursement model to include facilities outside of their service area will enable them to maintain a consistent rate structure while streamlining claims payment and predictive treatment costs.

The expanded agreement model developed by the firm in consultation with the payer organization is intended to improve coordination of care for out-of-area services while fostering collaboration and partnerships with national dialysis providers. In addition, the client will be engaging in Utilization Management, Care Coordination, and Physician Communication protocols to describe the enhanced network, expanding member access, and facilitating increased use of participating network provider facilities.

Giandana Healthcare Consultants not only developed overall contracting engagement strategy, but also educated staff on industry, reimbursement methodology, provided education resources, talking points and tools.

Deliverables included:

  • Strategy Document
  • Dialysis Plan
  • Workplan
  • Network Rate
  • Rate Scenarios
  • Competitive Information
  • Incidence in US
  • Network Configuration