Payer Contract Lifecycle Management

Payer Contract Lifecycle Management keeps your payer contracts, amendments and fee schedules in one place, with the terms modeled so they can be calculated. It compares what each payer actually paid on every remittance with what the contract says it should have paid, and turns the variances into worklists for appeals and payer follow-up. It also tracks renewal and notice dates, so negotiations start from evidence rather than from the calendar.

The problem it solves

Payer contracts are negotiated once, filed as PDFs, and then rarely consulted. Fee schedules change by amendment, carve-outs and escalators are buried in exhibits, and the expected reimbursement loaded in the billing system drifts from what was signed. Underpayments are spotted only when someone happens to notice, appeal deadlines pass, and renewal notices arrive with no clear picture of how the payer has performed under the current terms.

Who it’s for

• 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

1. Capture the contractEach 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.
2. Audit paymentsRemittances 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.
3. RecoverUnderpayments 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.
4. Renew and negotiateAhead 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.

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.

Contract manager

Owns payer contracts, models their terms and leads renewals

Underpayment analyst

Works variances, prepares appeals and records recoveries

Revenue cycle leader

Approves contract models, write-offs and priorities, and sees the whole picture

Finance analyst

Models rate scenarios and reviews expected revenue, without working variances

Compliance reviewer

Reviews flagged overpayments and decides on refunds under your policy

Auditor (read-only)

Views contracts, calculations and decisions without changing them

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.

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.

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.

Contract inventory

We gather your payer contracts, amendments and fee schedules and agree which payers and products to model first. We need the signed documents and a contact from your contracting team.

Term modeling

Payment terms are modeled for each contract and reviewed with your contract managers, who approve each model before it is used.

Data feeds

Claims and remittance feeds from your billing system and clearinghouse are mapped, loaded and checked for completeness.

Historical repricing

A period of historical claims is repriced and the results reviewed with your team, so tolerances are set and model errors corrected before variances go to analysts.

Workflow and roles

Worklists, assignment rules, write-off limits, appeal templates and roles are configured to match your procedures.

Training and go-live

Analysts, contract managers, compliance reviewers and finance users are trained on their own tasks, and payers are added in an order you choose.

• 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.

• Give us one payer contract and a sample of its remittances, and compare the variances found with what your team knows
• Check that each repricing calculation is clear enough for an analyst to confirm or dismiss without rework
• Review how a systemic issue is grouped and the evidence produced for the payer
• Walk through an overpayment flag with your compliance team
• Model a proposed rate change against your own volumes
• Confirm role separation: who can build, approve and change contract models, and who can write off a variance