November 02 2017 | 0 Comments | 195 reads Average Rating: 1

Formulating a Successful Value-based Equation for Provider-Led Health Plans

by Rodger Smith and EXL Healthcare in Payment Integrity

Healthcare organizations are preparing to succeed in a value-based world, where reimbursement will no longer be based solely on the volume of services delivered but on the clinical outcomes achieved.

This new model will require both providers and payers to give a little. Historically, health plans have been focused on controlling access and utilization in a quest to reduce costs – as they answer to employers or government payers. Providers, on the other hand, typically leverage their training to offer the procedures and interventions that will result in the best clinical care, as they try to meet myriad patient demands. Provider-led health plans aim to bridge this gap by ingraining much needed collaboration into the DNA of their organization.

4 Goals to attain

Indeed, value-based care requires a meeting of the minds, of sorts. By integrating payers’ claims data with providers’ clinical data, provider-led health plans can perform the data analysis that enables them to:

1. Better identify opportunities and act sooner.

2. Control costs.

3. Deliver better informed medical management.

4. Improve outcomes.

7 Best Practices to follow

To move toward realizing these goals, provider-led health plans need to employ the following best practices:

1. Zero in on risk adjusted lines of business, while streamlining documentation needs with quality initiatives.

2. Ensure claims accuracy and network efficiency.

3. Gain insight into your populations to prioritize resources and drive return on investment.

4. Identify which members most need to receive care management from a primary care physician.

5. Engage the right person (member or provider) with the right information at the right time.

6. Ensure that the primary care physician has complete information to manage patients’ conditions and to document that management appropriately.

7. Align financial incentives to encourage optimal care management and documentation.

3 Potential Results to experience

When provider-led health plans adopt these best practices, they can experience the following benefits:

1. Easy reporting to governing entities (CMS, NCQA) as they will have accumulated the complete claims dataset necessary for accurate score calculations.

2. Better pricing analysis and decision-making achieved through accurate utilization and cost information.

3. Improved quality and compliance by segmenting the population beyond risk to: prioritize members/resources for increased impact, engage members in the channels they prefer, and measure impact for continuous internal improvement and client reporting.

Here, we touched up the goals, best practices and results associated with provider-led health plans. For a more in-depth discussion, check out our webinar “Provider-Led Health Plans 202: A Roadmap to Ensuring Financial and Clinical Stability.” or VIEW SLIDESHARE.

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Rodger Smith
SVP, Payment Integrity

Rodger has over 16 years of operational and industry experience in healthcare, handling matters involving provider contracting, claims operations, provider and member dispute resolution, industry regulation, fraud, waste and abuse investigation, and Payment Integrity.

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EXL Healthcare

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