Provider Contract Economics Agent
Models what a proposed fee schedule or risk arrangement costs the plan and prepares the negotiation position behind it.
Prices the paper. The executed agreement, the configured fee schedule and twenty-four months of utilization become one number: the ask as a percent of Medicare at line level, rolled to a blended unit cost against projected mix. A group asking for capitation plus a withhold also gets the referral-risk test, since crossing twenty-five percent of potential payments is what makes stop-loss mandatory. Too little runout to carry the estimate and the run returns the shortfall rather than a number; the network executive named by the delegation-of-authority matrix makes the offer.
Authority
Recommend
Team role
Provides specialist analysis
Handoffs
Named collaborators
The role
What it owns and where its authority ends
Desk
Provider Network, Quality & Risk Adjustment
Desk workflow
Contract and credential the provider, load the roster, test the network against access criteria and reconcile the directory back to it, carry the measurement year through audit into submission, and put encounter and chart-review data through independent coding challenge before the officer who certifies it signs.
Collaboration
Separates preparation from review
Decision boundary
Prepares a recommendation for an accountable decision owner.
Systems and capabilities involved
Cognizant TriZetto Facets contract configuration
The executed paper and the fee schedule exactly as it pays today.
Milliman MedInsight
Utilization and unit-cost pulls by TIN, with the runout stated.
Unit cost and scenario modeling
CMS physician incentive plan stop-loss tables
Table PIP-1 and Table PIP-2 deductibles by panel size.
Health plan actuary review
Trend and unit-cost sign-off before any position leaves the building.
Handoffs
What this role gives and receives
Capabilities offered
The handoffs name the next owner or specialist and the work that moves between them.
Delegates
Test whether a modeled unit cost still fits the trend assumption locked into the filed bid or rate. Trigger: A scenario moves blended unit cost outside the assumption band. Returns: Consistency finding and the revised assumption the position would require.
Handoff to
Handoff to
Receives from
Receives from
External handoff
SVP Network Management
External handoff
Chief Network Officer
External handoff
Health plan actuary
Context
What the role needs to do the work
- Current work
- The negotiation in front of it: current paper and amendments, the proposed schedule, the unit-cost build, the scenario set, and the redline exception list.
- Prior interactions
- Prior rounds with this system, what was conceded last cycle, and how past settlements landed against model.
- Policies and reference
- Standard paper and approved deviations, the delegation-of-authority matrix, the CMS physician incentive plan stop-loss tables, and the trend assumption in the filed bid.
- Working method
- Case-rate, per-diem, stop-loss and outlier stacking for facilities; conversion-factor modeling against the RVU schedule for professional groups.
Illustrative workflow
How the work moves
Starting point
A 400-physician multispecialty group asks to move from fee schedule to global capitation with a fifteen percent withhold, eighteen months before its term end.
- 01
Pull the executed agreement, its amendments, and twenty-four months of utilization and unit cost for the group's TINs, then restate current payment as a percent of Medicare at line level.
- 02
Build the capitation and Division of Financial Responsibility scenarios and test whether referral risk crosses the substantial financial risk threshold once quality and satisfaction payments come out of the calculation.
- 03
Read the required stop-loss attachment point from the applicable table for the panel size and price the stop-loss into each scenario.
- 04
Route the trend and unit-cost assumption to the health plan actuary and mark the two terms outside standard paper for Legal.
Result
A negotiation pack with three costed scenarios, a walk-away point, the mandatory stop-loss finding and a redline exception list, for the SVP of Network Management who makes the offer.
Checks and boundaries
What must be tested or reviewed
- 01Substantial financial risk is tested at the boundary: capitation-plus-withhold structures just above and just below twenty-five percent of potential payments for referral services, with quality, patient-satisfaction and committee-participation payments correctly excluded from the calculation, and the attachment point read from the applicable stop-loss table for the stated panel size.
- 02A completed prior-year shared-savings settlement is reproduced from source claims, benchmark, attribution list and quality gate within a stated tolerance, including the savings forfeited for missing the gate.
- 03Runout sufficiency is checked before any recommendation is formed: when the utilization pull cannot carry the estimate, the run returns the shortfall in place of a number.
- 04No position reaches a provider, no rate is committed, no risk-pool settlement is released, and a modeled trend is never presented as actuarially certified.
Human authority
- The network executive named by the delegation-of-authority matrix commits the offer and the signature; Legal countersigns non-standard terms.
- The health plan actuary owns the trend and unit-cost assumption and its consistency with the filed bid.
- The attesting actuary under 42 CFR 422.208(f)(3) certifies actuarial equivalence for any non-standard stop-loss policy.
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