Years prior to the Affordable Care Act, our team of consultants had the great fortune of serving as the consultant to numerous employers, including one of the few healthcare providers in the country to be selected as a participant in the Center for Medicare Services (CMS) ACE pilot program. The ACE pilot program focused on performance-based initiatives, including global bundled payment arrangements. Upon completion of the program, our team was among the first consulting teams in the region to work collaboratively with this client, a handful of specialty providers and TPAs, to pioneer the first-to-market distribution of transparent, bundled payment programs to the commercial marketplace. As active students inside the walls of the healthcare providers we serve, our team is fully invested in the technology, data and resources necessary to keep pulse on the underlying regulation and cost-drivers of our healthcare system. By studying the trends and patterns taking place within the healthcare provider systems and operations, we are able to identify and plan for — well in advance — the leading market indicators that will have the greatest financial impact on our commercial health plan clients in the future.
With this healthcare industry experience as our framework, everything we offer within our health plan initiatives are based on reducing risk to the employer, increasing value to the plan sponsor and participant, and delivering the highest return on investment possible for both the employer and the employee. While plan design is a key component of any health plan, it has all too often been the sole strategy for many employers. The way we see it, plan design is a cost-shifting mechanism that is required from time to time to keep pace with inflation, but it is not a cost-reduction strategy long-term. Our actively-managed health plan model incorporates four primary levels of cost-containment strategy, with plan design being only one of those levels:
Level I: Negotiation
Level II: Plan Design Strategy and Utilization Management
Level III: Waste, Fraud & Abuse
Level IV: Prevention
Types of plans and programs that EmployerAdvocates assesses and negotiates on behalf of its clients:
Our diagnostic health plan assessments help employers turn their health plan data into actionable information. We have heard from employers for years who have said that their routine plan performance reports look pretty and give them some indication as to where they are today; but too often, there is nobody leading and guiding them to get to where they want to go. Employers tell us they struggle with the response from the market, “You had a bad claims year, so here is your renewal increase.” Oftentimes, there is little to no insight into the underlying cost drivers or creative cost-containment strategies to bend the cost curve for the long-term. Our health plan assessments and internal actuarial underwriting go beyond the spreadsheets and help employers better understand how the numbers get on the spreadsheet. We arm employers with the key information and underwriting factors so that they have the necessary information and understanding to hold their market underwriter, and even our team, accountable. We educate employers as to the underwriting process as well as help them identify the underlying cost drivers and what strategies are available to them to help mitigate their costs ongoing. Our diagnostic health plan assessments include:
Our teams have many years of experience in the evaluation and internal underwriting of both fully insured and self-funded health plans. We have developed a strong expertise in taking fully insured employers to self-funding, and vice versa. We have also helped employers evaluate and implement captive insurance programs and joint purchasing programs.
We are among the elite few consultants in the region who have truly specialized in the active-management of self-funded health plans and fully understand all the nuances of self-funding on both the market side as well as the employer side. We are also among the select brokerage consultants who bring depth of expertise in internally underwriting fully insured plans and running the checks and balances to ensure that your renewal is underwritten in an objective way that follows industry underwriting standards and is fair to the employer.
Using the employer’s own data, our custom funding analysis helps employers evaluate all of the many funding alternatives available to them, and allows them to make fully informed decisions about the funding program that is right for them. Our expertise includes the following funding models:
One key advantage of working with EmployerAdvocates is that our standard service model includes full-service internal underwriting capabilities at no additional cost to the employer. This means we do not reactively rely on the fully insured carrier or stop loss markets to project the annual liability of your fully insured or self-funded health plan. Instead, we bring the expertise internally at the consulting level where we are able to internally underwrite and project your complete liability and rate development for you—on your preferred time table.
This enables us to not only run rate development for the plan year, but also to run updated projections specifically for internal fiscal year budget purposes. Unlike the market underwriting, we incorporate all of the associated costs of your programs—including those outside the awareness of the stop loss underwriter. Where many self-funded employers are waiting down to the wire to obtain stop loss renewals and final projected liability, our clients have their numbers early and can plan ahead for budget and open enrollment purposes.
While we certainly run checks and balances between the internal underwriting and the market underwriting, we do not rely on outside sources or allow our clients to be held hostage to the market timeframes. Our underwriting systems were designed by actuaries. Our team of Dallas-based actuaries have fully vetted our local internal underwriting and rate development systems and processes. These actuaries provide ongoing collaboration and checks and balances of our underwriting, IBNR and budget methodologies.
Our internal underwriters are equipped to project not only the medical and pharmacy plan liability, but also dental and vision and other ancillary benefits on an integrated or stand alone basis. We are able to develop an integrated per-employee-per-month composite for budget purposes for those employers who prefer this methodology for their internal budget process.
For many employers with plan years that differ from their fiscal year, our teams will run the internal underwriting and rate development internally at renewal to help establish the employee rate increase or decrease; then we re-run the internal underwriting at fiscal year to help the employer establish their projected liability for the internal budget. Where an employer has a different plan year and fiscal year, these resources can be invaluable.
For our self-insured plans, our independent analytics system runs alongside the payer system and captures all the raw claims data. Our system enables us to actively monitor and generate reports and analytics on demand – without waiting weeks for carrier-level reports to come upon request. This system enables us to perform deep-dive analytics to determine what is driving the underlying costs of any given plan. Sometimes it is chronic conditions, sometimes the case mix, or perhaps a high cost drugs running through the medical plan that need to be negotiated. The drivers are as unique as the underlying plan members. We look for behavioral patterns and trends that could be curbed with strategic guidance, and we closely monitor the pharmacy programs for the greatest transparency and pass-through opportunities.
Our team of analysts recently instituted an internal claims audit process and has made this audit function a part of its standard active-management program. This internal audit process performs retrospective claim audits annually on the most recent 12 months of claims. It incorporates stratification and random sampling, combined with targeted audit methodologies based on the most common payment oversights, mis-codings and upcharges.
EmployerAdvocates receives universal monthly raw paid claims data into its system from the Third Party Administrator (TPA) and Pharmacy Benefits Manager (PBM). (Note: This electronic data feed is already established for all of the data analytics routinely provided to actively-managed plans).
Claims Payment Benchmarks
Our team then integrates comparative logic using the SPD provider guidelines, formulary and industry-standard algorithms such as AMA, CMS, FDA, and others in addition to proprietary logic based on our experiences in identifying common targets of waste, fraud and abuse.
Exception reports are then generated outlining any suspected errors and oversights in the payment methods. These exception reports are then submitted to the payer or to the provider for response and/or correction. If recoveries are made to the plan, 100% of the recovery is passed through to the plan for our actively-managed clients. These services can also be offered on a stand-alone basis for a fee or percent of savings.
Our consultants have been active students of accountable care for many years now and have worked closely with numerous healthcare providers understanding healthcare accountability and the value of reimbursement strategy since the initiation of the CMS ACE Pilot project in the early 2000’s. Our team has pioneered the provider performance monitoring efforts in Oklahoma among the consulting community. Having consulted for many years with numerous healthcare provider groups, our teams understand healthcare from inside the tent of the healthcare providers.
We understand firsthand the reimbursement methodologies and managed care contracting strategies. We know how to vet out the true net value of an entire healthcare delivery model, and not just the industry-reported network discounts. We know the net value of perfecting claims on the front end versus relying on the passive “pay and chase” model. This expertise adds significant value to the employer who wishes to truly save in overall claims expenses without either disrupting members or shifting costs to the employees to find employer cost “savings.” We are focused on truly cutting the costs of the underlying cost drivers – not relying on cost-shifting mechanisms.
Serving as a consultant to numerous healthcare providers over the years, our teams have developed firsthand expertise inside the world of managed care contracting. We understand the billing practices, the pricing models, the contract terms and provisions, and we understand that discounts are only a fraction of the total picture when it comes to evaluating network performance. Our teams are expert at evaluating network performance and determining the optimum network strategy for each health plan.
Our analysts go far beyond reported network discounts and perform deep-dive assessments of overall medical and pharmacy claims and provider performance on a systematic basis. We evaluate net-paid claim differentials on a risk-adjusted DRG to DRG and CPT to CPT basis. By risk-adjusting the variables and proactively identifying top-performing providers, plan members are encouraged to utilize the most cost-effective, high-quality providers for certain pre-planned procedures. We help employers set up their own preferred provider communities and preferred network tiers. EmployerAdvocates further offers a pre-registration and concierge referral process through its internally developed unit, the HealthcareAdvocate.
Our systems and processes have been developed to closely monitor provider performance patterns from both a cost and quality perspective. For each of our client groups, we will perform a 36 month lookback to determine which providers are most highly utilized under your plan. By comparing risk-adjusted metrics for the full episode of care, we can identify which providers are performing the most effectively from both a cost and quality perspective.
This process allows us to develop custom, value-based plan designs specific to an employer’s own plan utilization. Whether fully insured, self-funded in a bundled environment or unbundled environment, we can assist in developing steerage and education strategies to ensure that members are utilizing the most cost-effective, high quality providers. We deliver solutions to help steer your members to the right providers for significant cost savings to the plan and higher quality outcomes for your members.
Our team of consultants have actively led the direct global fee contracting efforts on the consulting side in this region. Upon methodically identifying the top performing providers from a cost and quality perspective, we have developed direct contracting strategies for our clients including global fee arrangements and shared savings models. We work closely and directly with top-performing providers to understand their billing practices and processes as well as the managed care contracting strategies to help implement these programs seamlessly from the administrative side.
Our fully integrated web portal connects our office and the provider to assist with the coordination of referrals, monitoring of our client member care and scheduling – for the highest quality and most seamless process for the patient. We have had enormous success helping our clients establish their own preferred provider tier 1 networks, wrapped with a broad based PPO network. Furthermore, where our clients have remote locations and struggle with access, we have had great success at negotiating direct contracts in remote areas to help the employer establish in-network contracts where key providers were previously out of network.
Our experts have developed numerous value-based plan designs that help employers get the greatest return on their investment. These programs focus on incenting employees for behaviors that result in higher quality outcomes and efficient cost savings to the plan.
Our programs offer access to an extensive database of market benchmarking tools to allow employers to benchmark their health plan programs by industry, size and geography. We help employers focus on developing health plan designs that enable them to remain competitive in their industry and determine where they may be more competitive than their peers. Where the client is more competitive, we leverage those opportunities to communicate the value back to the employees through open enrollment communications or custom employee communications off-enrollment cycle.
Our data analysts have access to sophisticated financial modeling tools that enable us to not only project overall plan liability, but also to benchmark high cost claimant diagnoses and determine how much liability to project for the go-forward. We closely monitor trends and perform custom financial modeling of various strategies, with integrated collaboration from our clinical care management council, made up of experienced specialty physicians and pharmacists.
Through incredibly sophisticated algorythms, our systems are able to perform individualized phenotyping – or risk stratification specific to each member’s level of predictive risk. Phenotyping customizes the predictive modeling not only based upon a member’s claims data and lab values, but also on specific behavior patterns, demographics, and the propensity for risk based on all of these individualize variables. We track specific claimants to help employers assess the risk of those members most likely to experience claims over certain thresholds within the next 12 months. These tools offer endless possibilities for helping employers prepare for the otherwise unpredictable liability expectations.
Our systems identify how many members in a given plan population have been diagnosed with chronic conditions. We then track which of those members are following evidence-based guidelines to help manage their chronic conditions. Where there are gaps in care, we often establish a central medical home manager to provide outreach and assist in closing the gaps in care. Our system fully integrates both claims and biometric lab data to identify those members who will be the next claim drivers, and ensure the most robust and proactive risk stratification possible.
Our teams have successfully developed central medical home models with complete clinical claims and lab value data integration and have negotiated onsite and near-site clinics to more proactively manage members with chronic conditions. We have found that where we have a primary care physician performing the ongoing outreach and consultations, we have greater engagement in chronic condition management programs and higher compliance rates with the HEDIS standards and evidence-based guidelines. As with most everything we do, these programs can be customized to suit the specific needs and interests of the client.
Our resources include integrated access to attorneys and financial consultants fully equipped to address all aspects of your regulatory planning and preparation. Our legal and consulting teams work collaboratively to help employers not only know what they need to do from a legal perspective, but also to let them know the financial impact of various regulatory recommendations. From ACA compliance, Cadillac Tax modeling, the impact of potential HIPAA violations or late 5500 filings, our teams collaborate to keep employers fully informed as to their regulatory requirements and financial consequences.
Our teams are expert at performing market research, due diligence and custom feasibility studies wherever employers need to assess their risk, reward, and expected outcomes. We have performed feasibility studies for providers looking to add healthcare clinics in a given geographic market, or for employers assessing the feasibility of adding an onsite clinic to their health plan strategy. Whatever the need, our teams are able to identify the needed market data to help assess potential strategies and help employers make fully informed decisions.
Upon implementing a given strategy, our team prepares an ROI assessment to identify how the program was performing prior to the change, and how it is performing after. Our ROI assessments might include segmenting a specific group of people – such as those who have gone through a wellness program, or those who visit a specific primary care physician. We can track the metrics of these given groups of individuals to compare average claims values before, during and after implemented programs. We can also compare and contrast these member metrics compared to the remainder of the population. Our ROI assessments are as customized as the solutions we measure. The important thing is that our recommendations are measurable and that we continue to monitor the outcomes and ROI to make adjustments wherever needed.
Our team of communication specialists offer custom communication programs and strategies for our clients. Each client has access to a graphic design specialist who is accessible to develop custom communication pieces and robust communications programming. Whether it be a wellness campaign roll-out, direct contracting solution roll-out, or simply your annual open enrollment communications, our communications teams stand ready to assist as an extension of your human resources staff. We further offer bilingual and multi-lingual communications support for clients who have need of such communication strategies.