North American Medical Management - California
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Management Services

Business Model

NAMM offers a full range of management services from which physician groups, IPAs and hospital systems may select to structure an arrangement most suitable for their needs.

What distinguishes NAMM beyond these core services, are its innovative approaches to adapt quickly by modifying its model as appropriate to suit the local market needs, and to align the interests of all providers to work toward mutual goals. NAMM is open to working with physicians hospital systems and health plans seeking affiliation options through management relationships, joint ventures and equity/ownership position by NAMM. The success of NAMM can be attributed to an operational and medical management infrastructure designed to promote coordinated care delivery systems.

Local Governance & Leadership Development

NAMM recognizes that health care is a regional business that requires the active participation and commitment of physicians.

If an organization expects physician performance that achieves superior clinical outcomes, delivers care efficiently and maintains exceptional patient satisfaction, it needs physician leaders who inspire and motivate. In each market, NAMM establishes an administrative office with an Executive Committee (EC) or Board comprised of and elected by practicing physicians in the IPA. The EC is charged with setting the goals and objectives of the IPA and executing the strategy required to meet them. A Medical Director approved by the EC oversees the local medical management initiatives. NAMM holds regional strategic retreats and an annual conference so the EC physicians may hone their leadership skills, discuss key industry events and/or legislation and be challenged to evaluate new approaches as their market changes. For day-to-day operations, NAMM provides on-site case management support with access to a best practices data warehouse, physician profiling and modeling reports to enable the EC to make decisions in the best interests of the patient base and IPA.

Network Integrity

Complementing the local governance structure created by NAMM, is the design of its physician compensation models to align interests in obtaining certain quality and strategic objectives.

NAMM is committed to continually evolving its model to provide value added services to support the viability of its Clients and the coordinated care model. Physician succession planning, joint ventures and staff models are a few of the initiatives currently underway in select areas. The model is flexible to adapt to changing priorities and the Client physicians have received very market competitive compensation under a capitated and incentive based payment arrangement. Financial surpluses in the IPA are shared with physicians and distributed based on quality and service indicators established by the EC. In the IPAs owned by our affiliate, PMNI, our dedication to these Clients has resulted in an unparalleled IPA statistic of having over 85% of membership under physicians contracted exclusively with the NAMM Clients for their HMO patients.

Limited Knox-Keene License

Our affiliated entity, PrimeCare Medical Network,Inc. holds a limited Knox-Keene license in the state of California.

These licenses are granted pursuant to the Knox-Keene Health Care Services Act of 1975. This license benefits affiliated physicians and payors in the following ways:

  • Ability to assume institutional risk enabling greater flexibility in contracting and increased negotiation parity for improved contract rates
  • Allows payors to focus on their core strengths by shifting services to a highly regulated entity with a long track record of success
  • Assumption of additional delegated responsibilities and increased control over the cost and quality of these services
  • Provides protection from requirement of additional financial reserves

Government Relations

In an increasingly competitive and regulated health care environment, NAMM recognizes the importance of staying apprised of pending legislation, and participating in the development of new policies.

NAMM has an excellent working relationship with the Department of Managed Health Care and the Centers for Medicare and Medicaid. The NAMM corporate counsel serves on the State’s work group for administrative simplification to provide guidance on establishing clearly defined regulatory standards, and actively participates on the California Association of Physician Groups Public Policy Committee. Our executives spend considerable time educating legislators on both the federal and state levels about the coordinated care model to ensure we have presence when governmental bills or other actions on health care are under consideration. NAMM believes physicians must assume a greater voice in shaping health care policy, so we organized our own Physician Public Policy Committee to discuss pending bills and meet with key political influencers. All these efforts enable NAMM to proactively act in anticipation of new local, state or federal directives.

Financial Management

The financial services provided by NAMM include:

Reporting and Analysis:

  • Generate financial statements and budgets, and perform analysis
    • Capitation
    • Contracts
    • Profit/loss by line of business
  • Model new compensation and incentive models based upon IPA criteria
  • Manage each IPA bank account and reconcile bank statements
  • Maintain financial controls
  • Audit and reconcile all Health Plan revenue collections, including risk pools
  • Perform A/P functions
  • Manage relational database of benchmarks and historical experience to ensure the quality and integrity of the data
  • Develop ad-hoc reports on a prior approval basis

Physician Capitation Management/Eligibility

  • Audit capitation reports and reconcile eligibility files
  • Create and maintain capitation system tables
  • Administer current capitation methodology, recommend available options

NAMM recognizes the need for accurate and timely data to effectively work within an increasingly complex health care reimbursement system, driven by new products, federal and state mandates, consumer demands, risk adjustors and quality performance indicators. To monitor care coordination efficiency and support our contracting team, NAMM has an extensive database of the expected specialty cost for each line of business and is able to use the information to monitor the reasonableness of specialty cost rates. NAMM has an Analytics Group staffed with seasoned professionals and supported by an extensive database of information. The financial models that this Group is capable of creating allows NAMM and its Clients to fully evaluate the potential scenarios when researching compensation structures, contracting changes, new HMO products and benefits,and plans developed by the Medical Management team for improved UM/QM performance. With Medicare HMO compensation based on the acuity level of members, the Analytics Group reconciles encounter data with CMS reports, and can project risk adjusted factor/medical risk adjusters by IPA and by physician to ensure that physicians are appropriately reimbursed for the care provided to a patient.

Eligibility

We currently receive 100% of our HMO eligibility information electronically from our contracted health plans. Loading it directly into our system ensures the accuracy, timeliness and integrity of the information the physician receives. We continuously update the eligibility information available online to physician offices and also provide monthly reports to their offices.

Contracting

Clients are able to capitalize on the established relationships that NAMM has developed with health plans and providers.

PMNI, a NAMM affiliate, holds a limited Knox-Keene license which enables physician partners to access full risk capabilities and to address recent legislative solvency requirements in a cost-effective manner. The negotiating parity NAMM has been able to obtain through their reputation as a quality organization has assisted Clients in receiving fair compensation for their medical services. Primary functions of the Contracting Department include:

  • Assist in development of IPA provider network
  • Negotiate health plan contracts
  • Maintain contract database for each Client
  • Maintain standard contract templates in compliance with plan and regulatory requirements
  • Act as primary liaison to health plans

Credentialing

The Credentialing Department is a fast paced department that works to ensure all contracted providers within NAMM are qualified and appropriately credentialed. We work collectively with our contracted CVO (Credentialing Verification Organizations) to ensure compliance with NCQA and other state and federal regulatory bodies, as well as provide on-going monitoring monthly to identify potential risks or poor quality behaviors within our network. Our experienced staff consistently receives high scores on all HMO audits. NAMM California has developed an expedited credentialing process enabling affiliated groups to add providers quickly and efficiently.

NAMM Case Management

Medical Management

  • Provides access to over 350 standard management reports
  • Reports are designed to support and improve physician care coordination decisions
  • Coding program to support accurate documentation and encourange annual visits by seniors to monitor their care

The NAMM Medical Management team and other departments have successfully worked with local Client leadership to craft concise plans to obtain a level of sustainable performance. Using the extensive analytical resources within NAMM, Medical Management evaluates profiling and utilization data with the Client to develop the actions required to promote cost-effective care. Components of a plan have included refinements in the physician compensation/quality incentive model, management of specialty and tertiary referrals, hospitalist programs, and specialty contract terms. Recognizing that engagement of the IPA is key to successful implementation, physicians committees participate in all phases of a turnaround, from the initial assessment to the implementation and measurement of outcomes. NAMM provides the focus and discipline required in these situations.

Coding Program

NAMM currently employs certified coders to educate physicians in capturing all the codes appropriate for a member’s condition to help promote RAF score accuracy. To support this accuracy initiative, NAMM has acquired software that alerts physicians to those patients in which prior year codes were not reflected in the current year annual health assessment as well as identifies potential coding opportunities. Incentive programs for both physicians and their staff have been developed to encourage scheduling an annual appointment for seniors so their diagnosis codes are properly documented in a timely manner. RAF scores by physician, as well as identification of the physician’s senior members that have not yet completed their annual visit, are provided monthly.

Claims Administration and Customer Services

For contact, mailing addresses and dispute information:



  • Input and process all claims received from providers with an average turnaround time of less than 20 days
  • Allow for professional and institutional electronic submission of claims
  • Audit claims processing for accuracy on a consistent basis using a random sample
  • Maintain telephonic customer service support with bilingual representatives
  • Audit encounter data submission by providers and to the health plans
  • Prepare checks and pay within the time frame provided by contract or by law
  • Staff and participate in all health plan audits
  • Configure system for contract and benefit loads

The Department consistently exceeds the standards of health plan audits. Our strong audit procedures and pre-check run reviews ensure the accuracy of payments before any checks are mailed out. NAMM is fully compliant with CMS, DMHC, and health plan claims payment requirements and has consistently scored in the top percentile on claims audits.

Customer Services responds to all provider and member inquiries, and contacts new senior members to confirm that they have received their welcome packet, and are familiar with the scope of services offered by the NAMM Client network. This service promotes member retention and satisfaction. Additionally, NAMM has developed a proprietary, electronic provider dispute resolution program that enables physicians to submit and track disputes on-line to reduce their administrative overhead.

Claims & Resolution Contact Information
Provider Dispute Resolution Information - AB1455  -  CMS Provider Disputes
CMS Non-contracted Provider Appeal Process

Value Added Services

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