Contracting Episodes

Kids authorized for private-duty nursing often can't get home from the hospital because the pediatric home health network that looks adequate on paper — hundreds of agencies — shrinks to a handful (roughly 8 of 200 in NJ) that actually take high-acuity pediatric cases, turning "authorized hours" into a false promise.

Most revenue cycle teams are chasing the wrong fire. Persistent underpayment, denials that don't respond to appeals, patterns nobody can explain — these are often contract problems wearing a billing problem's disguise.

Got a contract. The fee schedule is fine. Not great — fine. And now the question isn't can we do this. It's should we, and on what terms?

CMS has posted the LEAD (Long-Term Enhanced ACO Design) model application materials. Most ACO applications fail before they're submitted — not because organizations are ineligible, but because they were never really built for risk.

Why are employers paying up to four times Medicare rates for identical procedures? Dr. Kumar Dharmarajan joins Alex Yarijanian to break down incentive alignment, Medicare Advantage contracting, AI-driven engagement, and the structural pricing gap between MA and commercial markets.

How Health Tech Startups Can Win at Managed Care Contracting: Insider Strategies for Scalable Payer Partnerships.
This episode dives deep into the essentials of navigating managed care contracts as a health tech startup.

Whether you're a founder, operator, or policy strategist, you'll walk away with a clear understanding of how to position your company for payer partnerships, structure risk-based contracts, and avoid common pitfalls in the healthcare financing space. We explore real-world examp...

In this episode of the VBCA Podcast, host Alex Yarijanian delves into the complex issue of hidden healthcare fees, surprise billing, and the alleged antitrust activities surrounding out-of-network reimbursements. The discussion centers on MultiPlan, a third-party repricing company accused of collaborating with major insurers—such as UnitedHealthcare, Cigna, and Aetna—to suppress out-of-network payments, adversely affecting patients, providers, and employers.

The system used to pay for health care today does not encourage the integration of health care and social care, nor can it adequately adapt to the trending shift toward value-based payments for care — paying for better quality and better health outcomes. New financing approaches are needed to enable the health care sector to engage in activities that strengthen social care and community resource.

This episode is also available as a blog post: https://healthcare-wiki.com/2021/07/21/paying-for-bi...