WHAT WE DO
We were founded in 1994 when, for many providers, managed care was fairly new, relatively simple to deal with and had limited impact on revenues and costs. At our inception we focused on assisting providers create and operate PHOs (Physician Hospital Organizations) and mutiprovider networks and on evaluating and negotiating third-party managed care payer contracts. Since then we have expanded our services as our clients’ needs have grown. In addition to contract negotiations and integrated provider networks, our services now include those listed below. Although we have grown, we are not so big that we are unable to deliver a very personalized level of service to every client.
EMPLOYEE HEALTH PLANS
Managed Care Partners can assist you with…
- The evaluation and selection of third party administrators; drafting a request for proposal for TPA services.
- The evaluation and selection of stop loss insurance.
- Creating plan designs which incentivize utilization of the organization’s and affiliated physicians’ services.
- Determining if the plan designs are having the intended effect.
- Developing a custom local provider and tertiary network for the organization’s employee health plan.
- The evaluation and selection of provider networks (primary or wrap-around).
HOSPITAL-AFFILIATED PRACTICES
Managed Care Partners can assist you…
- Negotiate with physicians for practice acquisitions and employment.
- Draft physician employment contracts.
- Create financial pro formas and assist in establishing values for practices being considered for acquisition.
- Evaluate and recommend how practice acquisitions will be funded.
- Draft practice purchase contracts.
- Prepare annual budget and business plan.
- Prepare monthly income statement and balance sheet; perform banking functions.
- Provide ongoing executive and financial management for the practices.
For practices in the feasibility or development stage we will, with the hospital’s legal, financial, and other advisors, and in addition to the above:
- Suggest how the practices will be governed and managed.
- Draft organizational documents such as articles of incorporation, bylaws and operating agreements.
- Evaluate and recommend the organizational structure for hospital-affiliated practices.
INTEGRATED PROVIDER NETWORKS
(PHOs: Physician Hospital Organizations, IPAs, Physician Organizations, Accountable Care Organizations)
As your Provider Network Staff we will…
- Evaluate new payer arrangements as they are presented to the organization.
- “Messenger” offers, acceptances and counteroffers between payers and Network providers for non-risk contracts, and in that capacity:
- give Network providers information about a new payer including its existing clients and its current and projected lives in the Network’s service area,
- furnish Network providers with a summary of contract terms,
- prepare a comparison of the payer’s proposed reimbursement to other data bases and payer contracts,
- furnish the Network providers with descriptions of the products and plan designs offered by the payer, particularly those features which give patients an incentive to use the Network members’ services, and
- convey payer offers and provider acceptances or counteroffers between the parties.
- Evaluate and negotiate risk contracts.
- Administer delegated credentialing agreements including compilation of credentialing and recredentialing files for Network participating providers.
- Promote the Network and the services of its participating providers to third party payers, area insurance agents, employers and plan participants.
- Prepare annual budget and business plan.
- Prepare monthly income statement and balance sheet; perform banking functions.
- Establish and monitor group purchasing programs.
- Attend Board and Committee meetings, prepare agendas, draft minutes.
- Review the Network’s current managed care agreements; prepare and maintain a written summary of each.
- Assist with renewal of existing payer contracts.
- Work with the Network to establish direct contracts with local self-funded employers.
- Assist the Network’s providers in auditing payers’ remittances and compliance with contract terms.
- Assist in resolving late or inaccurate payment problems.
- Conduct programs on managed care and related topics for staff, physicians, board members and the community.
Why Outsource Network Operations?
- Broader experience: Managed Care Partners administers more than 500 contracts for its client providers and has worked with over 100 different payers.
- Greater expertise: Managed Care Partners employs specialists in contract evaluation and negotiation, compliance, credentialing, reimbursement modeling and payment auditing.
- Up-to-date knowledge base: As a result of working with payers and providers every day, the knowledge of the team handling your contracts remains current.
- No employment relationships: The engagement may be terminated at any time.
- Lower cost: Your cost will be much less than that of employing individuals with comparable experience, and you will no longer incur the cost of an office or other overhead.
MEDICARE ADVANTAGE
In 2009, according to the Congressional Budget Office, the benefits for the four parts of Medicare were projected to be $484 billion. Of the forty-five million elderly and disabled Americans who receive health insurance benefits from Medicare, approximately twenty-five percent are in Medicare Advantage plans. It’s no wonder the payers are almost frantic in their efforts to increase the number of seniors enrolled in Medicare Advantage plans and, by extension, increase their piece of the $360 billion pie they do not now have.
Medicare Advantage is the next slippery slope in managed care. Fifteen to twenty years ago, managed care was often just small discounts on charges, and there were few payer rules and procedures with which providers had to deal. As we all know too well, that is not how it is today.
Payers can make joining their Medicare Advantage plans sound as good and simple as entering into commercial managed care did two decades ago. Many Medicare Advantage plans profess to pay providers the same as Medicare and follow CMS policies. What’s the harm in that? Not much, of course. Were it completely true, applicable to all plans and not likely to change, this would be easy. But it’s not, and it isn’t
Consider just some of the differences to be encountered with many Medicare Advantage plans compared to Original Medicare:
- reimbursement is the lesser of charges or what would have been paid by Original Medicare,
- a shorter time to file claims,
- drug formularies,
- no payment for bad debt,
- sometimes higher out-of-pocket expenses for seniors,
- prenotification or preauthorization requirements, and
- for providers whose reimbursement is cost-based, no settlement process.
To make the slippery slope a little less steep, Managed Care Partners will:
- identify the Medicare Advantage plans available to seniors residing in your service area,
- help you devise a strategy for dealing with Medicare Advantage,
- evaluate and negotiate Medicare Advantage payer contracts,
- check the payments of Medicare Advantage payers to see if they are reimbursing you according to contract terms,
- assist you in recovering underpayments exposed by the payment audit, and
- help you communicate with your senior community about their Medicare options.
OUTSOURCED MANAGED CARE DEPARTMENT
As your Managed Care Department we will…
- Evaluate new payer arrangements as they are presented to the organization.
- Negotiate terms with those payers with whom the organization wishes to have a contract.
- Calculate the financial impact of payer offers; suggest counteroffers.
- Review the organization’s current managed care agreements; prepare and maintain a written summary of each.
- Compare reimbursement terms of your various contracts.
- Make recommendations concerning changes in payer agreements.
- Work with the organization and medical staff to establish direct contracts with local self-funded employers.
- Assist the organization’s staff in auditing payers’ remittances and compliance with contract terms.
- Assist in resolving late or inaccurate payment problems.
- Evaluate and negotiate risk contracts and bundled service arrangements.
- Handle day-to-day communications with payers and renewal negotiations on existing contracts.
- Conduct programs on managed care and related topics for staff, physicians, board members and the community.
Why Outsource Your Managed Care?
- Broader experience: Managed Care Partners administers more than 650 contracts for its client providers and has worked with over 100 different payers.
- Greater expertise: Managed Care Partners employs specialists in contract evaluation and negotiation, compliance, credentialing, reimbursement modeling and payment auditing.
- Up-to-date knowledge base: As a result of working with payers and providers every day, the knowledge of the team handling your contracts remains current.
- No employment relationships: The engagement may be terminated at any time.
- Lower cost: Your cost will be much less than that of employing individuals with comparable experience, and you will no longer incur the cost of an office or other overhead. Fixed monthly fee insures no surprises.
PAYMENT AUDITS
Once upon a time, the negotiation of a managed care contract was the hardest part. Now, making sure that you are being paid according to the terms of the agreement is equally important.
With many services reimbursed at fixed amounts (e.g., DRGs; per diems; rates per case, visit or unit; lab, radiology and professional services fee schedules) rather than a percent of charges, the opportunity for a payer to make a mistake is great. And then there’s the confusing rock-paper-scissors hierarchy of payments (e.g., reimbursement for emergency department services is rolled into the outpatient surgery case rate if the patient is admitted for surgery from the ED).
Managed Care Partners will assist in the verification of payment accuracy and timeliness. The purpose of the verification process is to a) identify the claims where the payer’s allowed amount is different than the contract’s rate and b) compile the data necessary to appeal any mispayments. Often this begins with a sampling of several commercial and Medicare Advantage payers’ claims which then moves to an in-depth examination of claims for those payers who fail the initial sampling. We can also examine all claims for all commercial and Medicare Advantage payers on a quarterly basis.
Where we are providing ongoing services for our Managed Care Department and Integrated Provider Networks clients, the sample verification is included in their fee. The cost for quarterly auditing is based on the number of payers, expected claims volume, the fee structures within the payer contracts and the availability of electronic claims data files from the provider.
Salary Vs. Hourly Compensation
Because we view ourselves as your employees and not as consultants, our compensation, when we are engaged as your Managed Care Department or provide ongoing services to Integrated Provider Networks, is a flat monthly “salary.” We like these relationships, and our clients do, too, because we become far more involved with the client’s organization, and there is no reluctance on their part to bring us in when our expertise might be utilized. Besides, it is by far, the best economic arrangement. Our “employment” can be terminated at any time simply by giving us thirty days written notice.