Health Insurance Provider Contracting and Payment Training Course

Course overview

Health plans, provider organizations and third-party administrators depend on contracts that translate accurately into network configuration, claims adjudication and provider reimbursement. Weak language around fee schedules, medical-necessity rules, authorization, modifiers, value-based incentives or payment disputes can create avoidable denials, underpayments, overpayments, provider abrasion and financial leakage. This course addresses the operational gap between negotiating a provider agreement and administering its payment terms reliably across contracting, credentialing, network operations, claims and finance teams.

Participants learn to interpret and draft core provider contract provisions; build fee schedules and reimbursement exhibits; assess payment methodologies including percentage-of-Medicare, per diem, DRG, APC, capitation and case rates; and convert negotiated terms into auditable configuration requirements. The programme examines provider directory obligations, delegation, credentialing dependencies, timely filing, prior authorization, coordination of benefits, claim edits, recoupment, appeals and dispute-resolution clauses. Participants also use claims and remittance data to test contract compliance, identify reimbursement variance and prepare a defensible payment-recovery or correction case.

Instruction combines contract-markup workshops, payer-provider negotiation scenarios, reimbursement calculations, X12 transaction analysis and operational case studies. Working from a realistic hospital and physician-network agreement, each participant develops a provider contracting and payment implementation pack: a contract issue log, payment-methodology comparison, fee-schedule control sheet, configuration requirements matrix, claims-audit plan and escalation workflow. The deliverables can be adapted for use in a health plan, provider revenue-cycle office or managed-care contracting function.

The course is designed for experienced professionals who already work with healthcare contracts, network operations, claims, reimbursement, revenue cycle or provider relations and need stronger command of the commercial and operational consequences of payment terms.

Course objectives

By the end of this course, participants will be able to:

• Interpret provider agreement clauses governing reimbursement, authorization, claims submission, audits, recoupment and dispute resolution
• Construct fee-schedule exhibits using CPT, HCPCS, modifier and place-of-service payment rules
• Compare DRG, APC, per-diem, case-rate, capitation and percentage-of-Medicare reimbursement methodologies
• Translate negotiated contract language into a claims-configuration requirements matrix
• Validate claim and remittance transactions using ANSI X12 837 and 835 data elements
• Calculate expected reimbursement and isolate variance between contracted and adjudicated payment
• Design a provider payment-audit plan with sampling logic, evidence requirements and escalation steps
• Produce a contract implementation pack linking legal terms, operational owners, controls and go-live milestones

Benefits of attending

Target competencies

Who should attend

• Managed Care Contract Managers — who negotiate provider terms and need to ensure they can be administered accurately
• Provider Network Managers — who oversee network participation, provider communications and contract implementation
• Health Plan Claims Managers — who must align adjudication rules and payment controls with executed agreements
• Provider Revenue Cycle Directors — who need to validate payer reimbursement and pursue defensible underpayment claims
• Healthcare Finance and Reimbursement Analysts — who model payment methodologies and investigate reimbursement variance
• Provider Relations and Credentialing Managers — who manage operational dependencies between network status, directory data and payment eligibility

Requirements and prerequisites

Participants should have working experience in a health plan, provider organization, third-party administrator or healthcare advisory role, with exposure to provider contracts, claims, reimbursement, revenue cycle or network operations. Familiarity with basic medical billing terminology, including CPT, HCPCS, ICD-10-CM, claim, remittance advice, deductible and coordination of benefits, is assumed. Participants should be comfortable using Microsoft Excel for calculations and reviewing structured documents. Prior contract-drafting experience, legal qualification, coding certification, claims-system administration or prior knowledge of ANSI X12 transactions is not required; these are taught in applied context.

Training methodology

The course uses short instructor-led briefings to establish regulatory, contractual and payment concepts, followed by applied work on a simulated payer-provider agreement. Participants mark up clauses, calculate reimbursement under competing methodologies in Microsoft Excel, map contract provisions to claims-system rules and inspect sample ANSI X12 837 claims and 835 remittance advice. Small groups negotiate disputed terms and present a payment-variance finding. On the final day, each participant completes an application plan and implementation pack for a current or representative contract portfolio.

Course outline

Day 1: Provider contracting foundations and risk allocation

• Provider agreement architecture and hierarchy of contract documents
• Network participation, service-area and exclusivity provisions
• Credentialing, recredentialing and provider-directory obligations
• Scope-of-services definitions for facilities and professional providers
• Regulatory context for network adequacy, surprise billing and delegated functions
• Key contract definitions affecting claim eligibility and reimbursement
• Contract-risk issue logging and clause prioritisation

Workshop: Participants review a sample provider agreement and produce a ranked contract issue log identifying operational, payment and compliance risks.

Day 2: Reimbursement methodologies and fee schedule engineering

• CPT, HCPCS, revenue-code and place-of-service payment drivers
• Relative value units and conversion-factor fee schedule construction
• Percentage-of-Medicare reimbursement and annual benchmark updates
• DRG, APC and per-diem facility payment methodologies
• Case rates, bundled payments and stop-loss thresholds
• Capitation rate design, member attribution and risk corridors
• Modifier, bilateral procedure, multiple-procedure and assistant-surgeon rules

Workshop: Participants build and compare a physician fee schedule and hospital payment model in Excel, documenting assumptions and variance triggers.

Day 3: Turning contract terms into claims payment operations

• Contract-to-configuration requirements matrix design
• ANSI X12 837 claim transaction structure and critical data elements
• ANSI X12 835 remittance advice, CARC and RARC interpretation
• Authorization, referral and medical-necessity payment dependencies
• Timely filing, clean-claim and corrected-claim contract rules
• Coordination of benefits, subrogation and member-cost-share provisions
• Claims edits, pricing rules and configuration acceptance testing

Workshop: Participants convert selected contract clauses into a configuration matrix and test expected payment against sample 837 and 835 records.

Day 4: Payment integrity, variance analysis and dispute resolution

• Expected-versus-paid reimbursement variance calculation
• Claim-sampling methods for contract compliance audits
• Underpayment, overpayment and duplicate-payment investigation workflows
• Medical record, authorization and remittance evidence collection
• Provider audit rights, records access and recoupment limitations
• Appeal, reconsideration and payment-dispute clause design
• Root-cause analysis for recurring pricing and adjudication defects

Workshop: Participants conduct a mini payment audit, quantify reimbursement variance and prepare a documented provider or payer escalation case.

Day 5: Negotiation, implementation governance and portfolio control

• Negotiation preparation using reimbursement scenarios and concession limits
• Service-level agreements for claims accuracy and payment timeliness
• Value-based payment measures, quality gates and data-reporting obligations
• Amendment, renewal, termination and continuity-of-care provisions
• Delegation oversight and downstream provider payment controls
• Contract implementation governance, RACI and go-live checkpoints
• Portfolio dashboards for contract status, payment variance and dispute ageing

Workshop: Participants present a provider contracting and payment implementation pack containing governance milestones, payment controls and a 90-day action plan.

Tools & standards covered

Microsoft Excel, ANSI X12 837, ANSI X12 835, CMS-1500

A typical training day

Live online deliveries follow the same structure in the East Africa Time zone, with shorter screen blocks and longer breaks.

What the fee includes

How you can take this course

Certification

Participants who complete the full five days receive the Skillset Development Certificate of Completion, stating the course title, course code, dates and delivery format — suitable for professional-development records and employer reimbursement.

Frequently asked questions