Business Spotlight
At Athena Group, we impart the wisdom of integrating health plan contracts and medical management staff into a strategic model that uplifts the healthcare industry.
Explore our resources to gain crucial insights, learn from your industry counterparts, and embark on the path of optimized healthcare management. If you have questions about our healthcare consulting services, please contact us today.
Dissecting the Challenges in Healthcare
In a time where many are confused about the direction of Health Care we look toward the future. Regardless of the design one thing is clear, we need more accountability in health care. The value-based payment model is inevitable and will ultimately shape the future of healthcare in a way that will be mutually beneficial to patients, providers, and payers.
Licensing
- Situation
A Large IPA in California was looking to take on more risk to be able to generate additional revenue to invest in medical management and other benefits to better care for their patients. This requires a Knox Keene License in California working with the Department of Managed Health Care (“DMHC”) - Problem Assessment
The IPA needed assistance in obtaining the required licensure to take on the risk and related revenue to be able to invest in their patients. The regulations in California can be burdensome. The process to obtain a Knox Keene license in California can require significant time and resources that would take the IPA physicians and administrators away from patient care. They needed someone to coordinate all the resources and manage the California regulatory process. - Actions
The IPA contacted Athena. Athena took on the management of the process and coordinated all the resources required for the Knox Keene license. Often times this requires legal, actuarial and finance resources. Athena was able to put together the team to complete the required filing and follow up comment letters from the DMHC. - Results
The IPA was able to secure the Knox Keene license from the DMHC. The expertise of the Athena team was also able to complete the process in less time.
Hospital Contract Assessment
- Situation
The hospital had a recent turnover in contracting staff. There was no source of contracting terms and conditions. - Problem Assessment
The hospital was losing out on additional revenue due to the lack of management of contract renewals. Several contracts had pending renewals that had missed the renewal date and were not finalized. One contract had been completed but never returned to the hospital, and rates never loaded. - Actions
A complete contract assessment of all health plan contracts was performed, including key provisions such as rates, last renewal, effective date, and other operational issues. A complete assessment was documented and provided to the hospital. This assessment included a write-up for each health plan contract. The write-up included a summary of the position of the contract and actions needed. Actions included operational improvements and re-contracting if needed. - Results
Contracts were updated with better terms and rates. A tracking system was devised to track renewals and the status of contracts until final loading by the health plan and filed by the hospital.
IPA Physician Re-Contracting
- Situation
IPA Specialty Physicians were almost entirely capitated. The Specialty costs needed to be contained. - Problem Assessment
The Specialty Physician capitation did not align with IPA revenues and provided no incentive to control costs. - Actions
A competitive assessment of capitation rates and range of services by specialty was performed. The assessment was translated into new rates, and a risk pool distribution percentage was calculated. Specialty Physicians were contracted at new rates. Rates were also tied to revenue. The revenue tie-in incentivized the physicians to help the IPA gain more from the health plans. Also, as the physicians now shared in risk pool distributions, they were more aware of actions on the entire IPA financials. - Results
Action results include completion of re-contracting in three months, reduction of expenses, and enhancement of revenue. An added benefit was the increase in customer satisfaction. The physicians were incentivized to keep patients happy and maintain a good IPA reputation. The improved customer satisfaction enabled contracting staff to get larger increases, putting more dollars in the physician’s hands.
IPA Administrative Cost Reduction
- Situation
IPA Operations were inefficient and not responsive to customers. Administrative costs were running 16% of revenue. - Problem Assessment
Operational staff was aligned by function. They could not understand the details of the health plan contracts. They also did not communicate with other departments. The operational disconnection created a significantly long time to resolve issues. It resulted in the identification of duplicate work efforts. - Actions
We placed staff on teams from all areas, including Claims, Customer Service, and Medical Management. The teams were aligned according to health plan. The teams were then trained on the details of the health plans they managed. - Results
Staff was reduced, the accuracy of work was improved, and the time to resolution was improved. Overall administrative costs were reduced from 16% to 11% of revenue.
Client Testimonials
We have had the privilege of serving clients across the healthcare spectrum. Our team can provide a comprehensive list of current and past clients who have benefited from our services. If you are interested in referrals or require more information about the clients we have served, do not hesitate to contact us.
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