“Managed Care Tips and Tricks for Success”


Lori Martin
VP, Managed Care
CureIS Healthcare
C:360-907-2706
lmartin@cureis.com

Participating in Value-Based Care initiatives requires a well thought out approach in order to control both outcomes and cost while remaining fully compliant. Maintaining workflow efficiency is critical to ensure you continue providing quality care to your members/patients. If your organization is considering joining this growing trend in healthcare delivery or are looking for a tune up of your current processes, there are a few things to consider that will help lay the foundation for your success.

Increase end‐user and management confidence in your practice management system.
Confidence in your claims processing system only occurs when all the pieces of a puzzle are working together. Start by identifying key performance measures and audit all critical elements. By doing this, you will understand your ‘current state’ condition. Knowing where you stand is a necessary component to understanding both where you want to be and what you need to do to get there. Understanding the gap between your current state and desired outcome will provide a clear perspective of the steps needed to achieve your goals. This process will allow you to build a measurable, attainable and profitable plan that will become a starting standard to guide your journey to greater success.

Identification of the services to be managed that you are at risk for.
If you are a third party administrator, having confidence in your medical management and claims processing workflows is critical. The time and resources it takes to complete a process directly impacts your cost to provide quality care. Streamlining workflows and decreasing end-user decisions reduces your administrative expenses. One example is increasing your first-pass adjudication process. The effects of this change will be:

  • Reduced claims turn‐around time
  • Less manual adjudication decisions made by individual processors
  • Reduced error rate of claims processing and the cost of subsequent claims reprocessing
  • Increased transparency of the adjudication process

Develop the ability to measure key metrics and have strategies to manage variances.
Value-Based Care requires that you combine financial and clinical data. Integrating the data into a usable format is crucial.

Having critical data compared to metrics allows for the development of a plan to mitigate the differences (gaps) and move toward attaining established goals. Without this ability, managing variances is at best a guessing game, if it exists at all. Often, minor improvements illuminate new opportunities that will increase efficiencies and improve processes.

Improve individual and team accountability.
Staff participation in workflow analysis brings a team together and creates an atmosphere of responsibility and collaboration. Establishing an environment that encourages, inspires and motivates people to contribute ideas and suggest innovation takes exemplary leadership. Leadership does not require a title and can come from all or multiple levels of your organization. Fostering a workplace that rewards participation, contribution and some risk-taking empowers staff to take the initiative and provide potentially game-changing ideas.

Develop the ability to maintain system controls over the long‐term.
By accurately identifying current state and establishing measurable, attainable and profitable goals you are well on your way to achieving success. Establishing performance benchmarks, developing variance tolerance degrees, instituting a monitoring and measurement system to track progress and following a standard guideline for ‘course corrections’ is critical to ensure program sustainability. By doing so, you will be able to celebrate achievement, make adjustments to the plan and continue moving your organization forward.