Management services

We can adapt quickly and change the business model to suit your needs. We want to align the interests of all providers to work toward the same goals.

Our business model promotes coordinated care delivery. We work with physicians, hospital systems and health plans that want affiliation.

We know that health care is a regional business. We need physician leaders who inspire and motivate. This requires their active participation and commitment.

In each market, we have an IPA administrative office. This has an executive committee (EC) that includes practicing physicians within the IPA. The EC sets goals and objectives, and determines the strategy required to meet them.

A medical director who's approved by the EC oversees the local medical management initiatives. This includes retreats and an annual conference focused on leadership development. It also includes on-site case management support.

We are committed to supporting a successful client and coordinated care model. We do this by always making sure that our model offers value-added services.

Our physician compensation model is flexible and complements the local governance structure we created.

Contracted physicians receive market based capitation along with a quality performance based incentive pay arrangement. Financial surpluses in the IPA are shared with physicians and distributed based on quality and service indicators established by the MSO.

Some current initiatives in select areas include:

• Physician succession planning
• Joint ventures
• Staff models

In an increasingly competitive and regulated health care environment, we know how important it is to stay informed. That's why we proactively anticipate new local, state or federal directives.

We also have an excellent working relationship with the Department of Managed Health Care and the Centers for Medicare and Medicaid Services (CMS).

We believe doctors must have a greater voice in shaping health care policy. That's why we organized our own Physician Public Policy Committee. This group talks about pending bills and meets with key political influencers.

Our corporate counsel serves on the state’s work group for administrative simplification. They offer guidance on establishing clearly defined regulatory standards.
The counsel also participates on the California Association of Physician Groups Public Policy Committee.

Our executives spend a lot of time educating state and federal legislators about the coordinated care model. This ensures we have a voice when governmental bills or other health care actions are being considered.

We have an expedited credentialing process. This helps affiliated groups add providers quickly and efficiently.

The credentialing department ensures all contracted providers are qualified and appropriately credentialed. We work with our contracted Credentialing Verification Organizations (CVO) to ensure compliance with NCQA and other regulatory bodies.

We also offer monthly monitoring to identify potential risks within our network. Our experienced staff consistently receives high scores on all HMO audits.

We have relationships with health plans and providers, which clients can benefit from.

PrimeCare Medical Network, Inc. (PMNI), an Optum affiliate, has a limited Knox-Keene license. This gives physician partners access to full-risk capabilities and address recent legislative solvency requirements in a cost-effective manner.

Our contracting department:

• Helps develop IPA provider networks
• Negotiates health plan contracts
• Maintains contract databases for clients
• Maintains standard contract templates
• Acts as primary liaison to health plans
  

Currently, 100% of our HMO eligibility information comes from contracted health plans. We load it into our system to ensure accuracy and timeliness. We update this information online often. We also provide monthly reports to physician offices.

Our marketing campaigns are implemented to target audiences to support the sales team, help retain members and promote the client brand identity. 

The marketing and sales team analyzes each market and creates a customized plan for each client. The team can also quickly deploy new strategies to address unforeseen events and new opportunities. 

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We provide clients with effective and efficient IT systems that are at the forefront of health care and technology.

The IT department continuously evaluates upgrades and ways to expand the electronic capabilities for us and our clients.

We use several best-of-class vendors. This helps us support and host systems for communication, automatic authorizations, eligibility tracking and transactional claim processing.

Our data aggregation processes and security protections are approved for self-reporting data. This is for various pay-for-performance and quality assurance programs that improve patient care quality and encounter submission accuracy.

Our provider portal includes a single point of communication for online access to:

• View member eligibility
• Look up claims
• Submit and review authorizations and referrals
• Order and review laboratory results
• View and update IPA and provider-specific details

We want to improve physician online access by streamlining medical management and physician communications. That's why we implemented our EHR/PMS system in 2009.

Our portal offers innovative self-service web solutions that help physicians with decision support strategies. These strategies eliminate the need for authorization phone calls and faxes, and reduce administrative overhead.

To improve coordination of patient care and help physicians qualify for federal funds under the HITECH Act, we recrafted our connectivity strategy to include a HUB technology.

This helps with communication among different EHR/PMS systems, physicians, hospitals and ancillary providers. It also improves clinical pathways for disease management, patient portals and data aggregation for best practice studies.

Our claims administration and customer service departments:

• Process claims from providers in 20 days or less, on average
• Offer electronic claim submissions
• Use random samples to audit claim processing accuracy
• Offer telephonic customer service support with bilingual representatives
• Prepare checks and pay accurately within the time frame set by contract or law
• Staff and participate in all health plan audits
• Configure systems for contract and benefit loads

We strive to exceed the standards of health plan audits. 

We fully comply with CMS, DMHC and health plan claims payment requirements. 

Customer service responds to all provider and member inquiries. We also contact new senior members to make sure they know about our services. This service helps us retain members and make sure they are satisfied.

We also have a proprietary, electronic provider dispute resolution program. This lets physicians submit and track disputes online, which reduces their administrative overhead.

We offer access to more than 350 standard management reports to support:

• Physician care coordination decisions
• Accurate documentation
• Annual visits with those age 65 and older

Our medical management team and other departments work with local client leadership to create concise plans that lead to sustainable performance.

Using our extensive analytical resources, medical management evaluates profiling and utilization data with our clients. This helps us promote cost-effective care.

Components of a plan have included:

• Refining the physician compensation/quality incentive model
• Managing specialty and tertiary referrals
• Hospitalist programs
• Specialty contract terms

We know that IPA involvement is key to successful implementation. That's why physician committees participate in all phases of a turnaround.

From the initial assessment to implementing and measuring outcomes, we provide the focus and discipline required.

We currently use certified coders to help physicians learn how to capture all codes required for a member’s condition. This helps promote Risk Adjustment Factor (RAF) score accuracy.

To support this initiative, we acquired software that identifies potential coding opportunities. The software also alerts physicians to patients whose previous year's codes weren't reflected in the current year's annual health assessment.

We also have incentive programs that encourage physicians and staff to schedule annual visits for those 65 and older. This ensures their diagnosis codes are documented accurately and timely.

Each month we get RAF scores by physician, as well as the physician’s members 65 and older, who have not yet completed their annual visit.

We offer care management programs to groups that focus on people 65 and older. We also offer a physician-run program with significant nursing support. 

View or print a copy of our Case Management brochure.

We offer several financial services. 

Reporting and analysis:

• Generate financial statements and budgets, and perform analysis for the following:
  •    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 and recommend available options

We know we need accurate and timely data to effectively work within an increasingly complex health care reimbursement system. This work is 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, we have the expected specialty cost for each line of business. We use the information to monitor the reasonableness of specialty cost rates.

We have an analytics group staffed with professionals and supported by an extensive database.

The financial models created by this group helps us and our clients evaluate potential scenarios.

These include researching compensation structures, contracting changes, new HMO products and benefits, and plans developed by the medical management team to improve UM/QM performance.

With Medicare HMO compensation based on the acuity level of members, the analytics group reconciles encounter data with CMS reports. This group can project risk adjusted factors/medical risk adjusters by IPA and physician.

This helps ensure that physicians are appropriately reimbursed for providing care to a patient.

Our affiliated entity, PrimeCare Medical Network, Inc., holds a limited Knox-Keene license in California. These licenses are granted according to the Knox-Keene Health Care Services Act of 1975.

This license benefits affiliated physicians and payers in the following ways:

• Ability to assume institutional risk with flexibility in contracting and increased negotiation for improved contract rates
• Allows payers to focus on their core strengths by shifting services to a highly regulated entity with a 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