Vice President of Provider Networks

If you are responsible for your health plan’s provider network, you and your team must navigate significant changes in healthcare payment models and quality metrics that fundamentally change the need for interaction with your providers.  Gone are the days when you can rely on infrequent transactions with providers.  The financial health of your plan depends more heavily on an exchange of data with providers.

Your team must be able to interact with your provider network at a level of detail that was not necessary until now.  Most health plans relied on electronic claims processing and provider portals to address the transactional nature of your relationship with your network.  Now you must interact at a level of detail that can be as specific as a given procedure for an individual member.  Quality metrics like these are critical to a range of financial areas ranging from Medicare Advantage Star bonuses to the pay for performance models in ACO relationships.

Most health plans have limited infrastructure and information at the level of detail needed to make this transition.  Sending a letter to a provider with a list procedures or metrics may meet the necessary privacy requirements, but it is not easy for the provider to act on nor does it have convenient mechanism to provide you with feedback or updates.  The interactive future of your relationship with your network will require much more online engagement.

You and your team must work with a number of other functions to make sure the needs of the business are met.  IT wants to do end to end testing for the ICD-10 transition.  The Medicare Advantage team needs to manage the HEDIS metrics to get their Quality Bonus Payment.   Compliance has to assess for fraud, waste and abuse programs.  Managing a coherent approach to provider engagement is critical to ensuring the sanity of both you and your providers.

How We Can Help

Avior’s BenchMark platform is a Software as a Service platform designed to manage these kinds of secure interactions with large groups of third parties, like your provider network.   By having everything in one business grade database, you can make the interaction with the provider network much more efficient and effective.  We have a series of modules with all of the pieces necessary to implement a complete solution:

  • The Medicare Advantage Star Provider Engagement Module is designed to identify and mange the gaps in care by providing the tools to securely communicate bidirectionally with your providers.  You can provide information at an actionable level of detail while making it easy for them to provide feedback and updates.
  • You can use our platform to manage your compliance monitoring and auditing obligations under Medicare.
  • This provider engagement model can be extended beyond Stars to other quality metrics such as high risk medications and proper coding for CMS Hierarchical Chronic Conditions.  Making it easy for your providers to work with you maximizes your plan’s financial performance.  As you move to an ACO model, the metrics and interaction can be expanded for a truly compressive scalable and secure solution.

Avior CEO, Steve McCalmont, discusses the challenges facing health plans when working with providers in this installment of the Healthcare Insights Podcast:

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Watch the Webinar

5 Lessons from the Latest CMS Star Rating Data

In October, CMS released the Star Ratings which includes an enormous amount of data about the performance of all MA contracts. Avior has combined this data with enrollment data and done an extensive analysis. We want to share 5 critical lessons from this analysis:

  • Why one metric can tell you how well your providers can code
  • Which key metrics can be your canary in the coal mine
  • What enrollment trends tell us about how consumers view quality
  • How much of your rating is based on your location
  • How to compare your results to your competitors

These insights are important to anyone responsible for managing a plan's MA star rating. Join us for this 30 minute overview of our findings.

 

Did you miss our most recent webinars on Using Provider Engagement to Improve Your Star Rating? Watch the replay here.

Get our Stars White Paper

This paper explains the importance of automated provider engagement to improve your Medicare Advantage Star Rating and gives 10 criteria for a successful program.

Click to download

Aritcle by Avior

 

Seven health IT questions to improve pay for performance

Avior's CEO writes on the changing relationship between payers and providers.