Entering and Succeeding in Value-Based Contracts: The Provisions You Need to Protect Revenue and Support Performance

 

Whether your health center is evaluating its first value-based arrangement or managing a portfolio of them, the terms of the contract determine whether the model delivers revenue or risk. Health centers that have been in these arrangements report that health plans delay and deny the data and reports essential to managing clinical and financial performance, that member attribution shifts unpredictably due to Medicaid churn and other factors, and that health plans have increasingly sought recoupment of shared savings and capitation payments to correct their own miscalculations. Health centers considering a first arrangement can avoid these pitfalls by knowing what to ask for before signing.

 

This session starts with the fundamentals of value-based payment and how these arrangements work, then explains how more favorable contract provisions can provide a defense against these challenges. It will also offer suggestions on potential strategies to use in disputing recoupment demands based on a health plan’s miscalculation of payments.

 

The session will also briefly address two adjacent revenue opportunities: participation in Medicare accountable care organizations, and the FQHC payment protections available under Medicare Advantage, including the supplemental “wrap-around” payment and the “pay not less than” requirement.

 

Learning Objectives:



• Describe how value-based payment arrangements work and what a health center should assess before entering its first one.

• Identify the contract provisions that most often expose health centers and networks to downside risk and clawbacks under value-based arrangements.

• Apply model contract language governing data and reporting, performance benchmarks, dispute resolution, and recoupment finality when negotiating with health plans.

• Evaluate strategies for disputing recoupment demands arising from a health plan’s miscalculation of shared savings or capitation payments.

• Describe the key considerations in evaluating participation in a Medicare accountable care organization.

• Explain the FQHC payment protections under Medicare Advantage, including how the wrap-around payment is calculated and when it is and is not available.