SHARED RISK AGREEMENTS BETWEEN PCPs AND HMO PLANS ARE UPON US!

SHARED RISK AGREEMENTS BETWEEN PCPs AND HMO PLANS ARE UPON US!

By Pablo E. Silverio, HPP Management Group, Corp.

There are rapid and unavoidable changes taking place in healthcare, the P4P (pay-for-performance) new trend, the transition from the fee-for-service alternative, the demand of HEDIS measures, the formation of large physicians’ groups and ACOs plus the consolidation of insurance carriers leaves little room for the PCPs with small to medium size practices to survive. Shared risk agreements with HMO Plans are the survival tools.

A partnership using a direct shared risk management agreement between the PCP practices and HMO plans are upon us! It is fair deal, a win-win approach for patients receiving better care, for PCP practices getting paid what they deserve and for HMO Plans consolidating market share.

If your practice has an HMO Plan with over 750 Medicaid members and/or a Medicare Advantage Plan with more than 250 members, then you should really explore the possibility of having a shared risk agreement with a reputable HMO plan willing to partner with you.

Just think, if you have

·         An HMO plan with 1000 to 2000 Medicaid members and/or

·         A Medicare Advantage HMO Plan with more than 250 members

·         Your MLR (Medical Loss Ratio is the funding received to cost of medical expenses) is under 85%,

·         You are only paid a monthly PMPM capitation or receiving the fee-for-service amount paid for your claims, then you are, leaving thousands of dollars that belong to you on the table every year.

·         A Risk Agreement is justifiable if you know how to manage the HMO panel.

Many times, we talk to PCPs that are afraid to face a full risk agreement and prefer not to participate, not knowing what a risk operation is all about, what protections they have against catastrophic losses and most important, how to operate a successful risk agreement and be aware of the financial benefits of running a profitable HMO risk operation. What this means to you is the opportunity to be paid more for the same work done.

There are 3 basic steps to follow in preparation for a Risk Agreement operation:

·         First, a realistic analysis of your Medicaid, Straight Medicare and Medicare Advantage participation with HMO Plans will tell us what is your potential to pursue a full risk agreement with HMO plans.

·         You should prepare a business plan outlining what you and your practice are willing to commit to,

·         For sure, you will find a reputable HMO plan in your community willing to partner with you in a shared risk agreement. The shared risk agreement must between your practice and the HMO Plan.

If you need help preparing for the risk operation, find an independent source that can assist you to select a contract that is beneficial to you and fair to both parties, a team that is experienced in negotiating risk agreements with HMO plans. After you decide on the contract, then give the copy of the agreement to your attorney for a final look.

What are the key elements that HMO plans are looking for practices that deserve a partnership:

·         Solvency,

·         Several years of good practice with excellent acceptance from the community they serve

·         Patient acceptance and a commitment to excel in patient care

·         Proper licensing, fully compliance with CMS and AHCA guidelines and requirements

·         Understanding and timely control of coding and billing including HCC groups, MRA and HEDIS measures

·         Willing to learn the basic elements of risk operations including cost containment without compromising the quality of care

·         Combining and analyzing financial and clinical data to simultaneously maximize efforts and eliminate waste.

·         Major emphasis identifying patients with chronic conditions that demand special attention, in an effort, to control ER visits and admissions to hospitals, thus reducing the most exorbitant medical expenses

·         Attempt to achieve an 85% generic in Pharmacy, 4.5 HEDIS Rate and MRA 1.75

It is understood that in many instances, the PCP lacks the expertise to complete the key elements that HMO plans are demanding as a prerequisite for a risk agreement, requires that PCP practices form alliances with qualified organizations that can assist the practice with software and day-to-day support in the successful implementation and operation of risk management operations.

Our company and I stand ready to assist you in every step of the process.

Pablo E. Silverio is the President of HPP Management Group, Corp. of Miami, Florida

Risk Management Agreements Consultants

Developers of AccuChecker OnLine an MCAR - Risk Management Reports

Email: pesilverio@hppcorp.com

Website: www.accuchecker.com

Phone: 305-227-2383

Cell Phone: 786-231-7585

Medicare and Medicaid Audits and Appeals 2017

Medicare and Medicaid Audits and Appeals 2017

The Medicare and Medicaid programs employ a number of contractors to conduct audits of medical providers.  These contractors include the Medicare Administrative Contractors (MACs), the Zone Program Integrity Contractors (ZPICs), Comprehensive Error Rate Testing Contractors (CERT), Recovery Audit Contractors (RACs), and in the case of Medicaid in Florida, the Agency for Health Care Administration (AHCA), the Medicaid Fraud Control Units (MFCU), and the Medicaid Audit Contractors (MICs). 

The Medicare Administrative Contractor in Florida is First Coast Service Options (FCSO).  FCSO administers the Medicare program payments in Florida for Parts A and Part B.  In addition to processing claims for payment submitted by medical providers, FCSO also conducts medical review audits of claims submitted.  These audits can be either prepayment reviews, or post-payment audits. 

The Zone Program Integrity Contractor (ZPIC) in Florida is Safe Guard Services (SGS).  SGS is tasked with identifying potential fraudulent claims and providers.  As part of its benefit integrity function, SGS, along with its related contractor, IntegriGuard, conducts prepayment review audits of Medicare providers. 

The CERT contractors conducts post-payment audits to determine the percentage of Medicare claims submitted that are erroneous, that is, that should not have been paid.

Recovery Audit Contractors (RACs) are private companies under contract with the Centers for Medicare and Medicaid Services which have been tasked with identifying Medicare overpayments and underpayments and returning Medicare overpayments to the Medicare Trust Funds. RACs review claims submitted by health care providers and suppliers in an attempt to identify improper payments. Because RACs receive a portion of the improper payments they identify, the RACs are highly motivated to identify overpayments and other improper payments.

The RAC program began as a three-year demonstration program in 2005 in California, Florida and New York, the three states with the highest Medicare expenditures. In 2007, the program expanded to include Massachusetts, South Carolina and Arizona. The purpose of the RAC demonstration program was to determine whether the use of RACs would be a cost-effective way to identify and correct improper Medicare payments.

HPP Management Group, Corp. represent and defend providers and suppliers in all types of Medicare, Medicaid and other third party payer audits, appeals and controversies. We have the knowledge and experience to assist providers and suppliers in responding to audit requests in order to minimize the number of initial denials, as well as to successfully appeal any improperly denied claims. Please do not hesitate to contact us to discuss your particular situation.

For details please call 305-227-2383 or 1-877-938-9311 or  email:    psilben@hppcorp.com