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
Phone: 305-227-2383
Cell Phone: 786-231-7585
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