Payer Contract Lifecycle Management

Principal workflows

• Capture the contract: Each contract, amendment and fee schedule is stored with its effective dates, and its payment terms are modeled so they can be calculated: rates, methodologies, carve-outs, stop-loss and escalators.
• Audit payments: Remittances and claims are loaded from your billing systems, and each paid claim is repriced against the contract terms in effect on the date of service. Differences beyond your tolerance become variances.
• Recover: Underpayments are queued for analysts with the calculation behind the expected amount, grouped by payer and cause so systemic issues are raised once rather than claim by claim.
• Renew and negotiate: Ahead of each notice date, contracting teams see how the payer has paid under the current terms and can model proposed rates against your own claims history.

Who uses it

• Managed care and payer contracting teams at hospitals, health systems and physician groups
• Revenue cycle leaders who answer for net revenue
• Underpayment and denial analysts who work variances and appeals
• Finance teams who model contract changes and reserves
• Compliance staff who oversee overpayment identification and refunds

Reporting

• Open underpayment variances by payer, cause and deadline
• Recoveries, appeals and write-offs by payer and period
• Systemic payer issues and their escalation status
• Contract notice and renewal dates coming up
• Payer scorecards for negotiation
• Overpayment flags and their review status

Features

• Contract repository: Contracts, amendments, exhibits and correspondence stored together, with versions and effective dates so the terms in force on any date are clear.
• Payment term modeling: Fee schedules, percent of charges, per diems, case rates, DRG and APC-based methods, carve-outs, stop-loss and lesser-of provisions modeled so they can be calculated.
• Claim repricing: Each paid claim repriced against the contract version in effect on the date of service, with the calculation shown step by step.
• Variance detection: Expected and actual payments compared line by line, with tolerances you set, and variances classified by likely cause.
• Underpayment worklists: Variances queued by payer, cause, amount and appeal deadline, with assignment rules and team views.
• Systemic issue grouping: Variances with the same cause across many claims grouped, so a payer loading error is raised once with all affected claims.
• Appeal support: Appeal letters and payer inquiries prepared from templates with the claim, the expected calculation and the contract reference.
• Overpayment identification: Payments above the contracted amount flagged for compliance review, so credit balances and refunds are handled under your policy.
• Key date tracking: Term, renewal, notice, rate escalator and timely filing dates tracked with reminders to the contract owner.
• Rate modeling: Proposed rate changes modeled against your historical claims volumes, so negotiators can see the effect before agreeing.
• Payer scorecards: How each payer has paid under its contract: variances, recoveries, response to appeals and patterns over time.
• Complete record: Every term change, approval, variance decision and appeal kept with the person, time and reason.

Integrations

• Billing and patient accounting: Claims and account detail from your billing system by scheduled file or interface, mapped during implementation.
• Electronic remittance: Payer remittances from your clearinghouse or billing system, including adjustment and remark codes.
• Payer fee schedules: Fee schedules and rate files as supplied by payers or published for government programs, loaded and linked to contract versions.
• Denial management: Variances caused by denials passed to your denial management process, and denial outcomes received back.
• Document management: Signed contracts can be linked from your contract or document management system rather than copied.
• Single sign-on: Staff sign in through your identity provider (SAML or OpenID Connect).
• Work API: Expected payments, variances and recoveries available to your data warehouse and finance tools through the Moraph Work API.

Deployment

• Moraph cloud: Hosted and operated by Moraph in the United States region. United Kingdom and Australia regions are available for organizations outside the US.
• Dedicated environment: A single-tenant environment for health systems whose policies require isolation, scoped in the proposal.
• With a managed service: Optionally run alongside Moraph support for modeling new contracts and amendments and loading fee schedule updates.

Security and privacy

• Single sign-on: Staff sign in through your identity provider, so your password and multi-factor policies apply.
• Role-based access: What each person can see and do follows their role, facility and payer scope; building a contract model is separate from approving it.
• Protected health information: Claims and remittances contain patient information, so Moraph signs a business associate agreement and handles that information under it.
• Encryption and keys: Client data is encrypted, with keys Moraph staff cannot use without explicit, time-bound authorization.
• Complete audit trail: Every view, change, decision and export is logged with the person and time, and cannot be edited.
• Data residency: Data stays in the hosting region you choose: the United States, the United Kingdom or Australia.

Limitations

• Expected payments are only as accurate as the contract models. Terms are modeled with your team and approved by you, and ambiguous contract language is flagged for your decision rather than interpreted.
• It does not submit appeals or claims to payers. Your team sends appeals and inquiries through your usual channels and records the outcome.
• It is not a billing or claims scrubbing system. It works on claims after they are paid or denied, using data from your billing system.
• Moraph does not hold or collect funds. Recoveries are paid by payers to you through your normal remittance process.
• Identifying an overpayment does not return it. Refund decisions and any reporting obligations remain with your compliance team.
• Some payment methodologies need payer or government grouper and pricer data that you license; these are scoped during implementation.
• It does not provide legal advice on contract terms or disputes. Contract interpretation remains with your contracting team and counsel.
• Results depend on complete claims and remittance data; gaps in feeds produce gaps in auditing, which data quality checks report.

Next steps

Book a demonstration or a technical briefing at www.moraph.com/solutions/payer-contract-lifecycle-management. Purchasing routes and company information: www.moraph.com/how-to-buy.