Value-Based Care Strategy
Strategic planning, execution and continuous monitoring to ensure profitability under the new payment models
At B. Riley, we work with health plans and providers to help them thrive in the rapidly changing healthcare environment. Healthcare reform is a driving force for increased innovation between payers and providers. Reducing cost and improving the quality of care requires strategic planning, execution and continuous monitoring to ensure profitability under the new payment models.
B. Riley understands the impacts of healthcare reform and the shift from traditional fee-for-service payment models to value-based care. We assist payers in their shift to provider collaborative models, successfully navigating the ever-changing coverage and reimbursement guidelines serving as the driving force behind the need to increase quality of care while lowering cost. Our experienced professionals can provide the leadership to design new value-based product lines, develop go-to market strategies and measure outcomes to maximize profitability, while minimizing risk of new areas of regulatory exposure introduced by these innovative models. We can also provide independent and objective assessment of existing product line performance and operations for optimization.
B. Riley collaborates with clients to deploy solutions and initiatives that have positive financial impact. Our consultants provide deep insights that reveal opportunities, define strategies, guide your decision-making and implement meaningful change.
SOLUTIONS & RESOURCES
- Conducted an end-to-end analysis of the people, processes and technologies involved in risk adjustment data capture between a large integrated delivery system's hospitals, clinics and their respective health plan. The engagement included onsite observations and interviews with key stakeholders across the provider and payer organizations. The team completed a comprehensive assessment of the population health model leveraged to encourage patients to schedule their annual wellness visits, followed the patients through the continuum of care, reviewed templates and charge capture mechanisms within Epic (electronic health record "EHR"), assessed clinical documentation standards, employee training (both provider and payer) and traced data from capture in the physician office visit through receipt in the claims adjudication platform into the data warehouse and through the final filtering process for submission. Prospective, concurrent and retrospective auditing processes were also reviewed, as well as supplemental submission practices. A comprehensive report and work plan was provided aimed to strengthen internal processes, controls and improve risk adjustment data capture, as well as compliance with program requirements. Recommended strategies to improve community health record sharing leveraging technologies available. Completed similar engagements for multiple integrated delivery systems, as well as Medicare Advantage plans.
- Conducted a strategic analysis bench-marking a major payer's medical and payment guidelines, comparing benefits across competing plans. Identified strategic gaps in policy and provided recommendations to increase parity.
- Analyzed payment data on behalf of one of the nation's largest health plans to identify gaps in claim edits, which allowed reimbursement for services that should have been denied as non-covered.
- Conducted a CMS Readiness Assessment and NIST (National Institute of Standards and Technology) Controls Review for an internet healthcare broker as a CMS requirement of the broker's direct enrollment pathway. This was primarily focused on HIPAA Privacy and Security standards, providing an independent and objective assessment of the broker's risk mitigation program. CMS acknowledged the report as having set the standard for what others should strive to emulate.
- Served as faculty and featured speaker for the National Health Care Anti-Fraud Association (NHCAA) and America's Health Insurance Plans (AHIP), providing training to Federal Bureau of Investigation (FBI), Defense Criminal Investigation Services (DCIS) and private payer Special Investigation Unit (SIU) staff with respect to investigative techniques for identification of fraud, waste and abuse in the insurance marketplace.
- Act as an extension of the SIU for some of the nation's largest health plans, providing subject matter expertise on complex healthcare investigations involving suspected fraud, waste and abuse. This includes providing training and education on provider documentation, coding, billing and clinical operations to the internal investigation team, as well as traveling onsite to suspect provider locations, participating in unannounced inspections, interviewing key personnel and observing pertinent workflows. Additionally, the team analyzes reimbursement policies and conducts independent and objective assessment of provider documentation, coding and billing against coverage and reimbursement guidelines, provider manual requirements, as well as federal and state-mandated rules and regulations. Provide feedback on medical policies, as well as payment edits within the claim adjudication platform to optimize processing.