“Managed Care Tips and Tricks for Success”

Lori Martin
VP, Managed Care
CureIS Healthcare

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.


By Chris Sawotin | CEO

“Don’t be afraid of being outnumbered! Eagles fly alone. Pigeons flock together.”

I saw those words on a poster recently and immediately determined that the industry that we live and work in, healthcare, closely resembles this remark. I have often been perplexed by that circumstance and work daily to help change it.

In healthcare, it often seems that we have a flock mentality versus striving to be an Eagle-like organization. With such pressure on revenues from reimbursements, I find it hard to understand why organizations prefer complaining rather then changing. And even when they do change, the most asked question is “Who else is using this?” If everyone is using the same thing, then why is everyone (generally speaking) complaining that costs are too high and revenue too low?

It seems to me that if a healthcare organization, whether provider, payer, integrated delivery network, primary care physician, specialty organization, accountable care organization, independent physician association or a managed services business want to distinguish themselves they should look at doing things differently than everyone else.

Is it just that we are who we are and prefer the “flock” mentality to attempting to venture into unknown environments? And if the answer is yes, what does that tell us about our society, the way business is conducted and how we operate in the healthcare industry?

There are times and instances in our industry, with our flock mentality, where really valuable products never make it successfully to market because no one is willing to change and take the risk of implementing something different. Many good software applications are developed out of need by an Eagle-like organization that is willing to take the “risk” to get a better product into their environment. And the irony is that most of the systems that fall short in some way and allow for the development of new products are those very same systems that people flock to when buying product.

I suppose that we live in a world where people generally behave like pigeons and flock together because there seems to be safety in numbers. I also suppose that it is our nature to gravitate toward safety.

However, many great inventions, feats and events have happened when someone dares to be different and goes against the crowd. We all could name a famous person who displayed these traits and had the Eagle mentality. But one of my favorite Eagle mentality stories tells of an ordinary cab driver who decided to operate his cab more like a limo service and made a wonderful living doing so.  Those around him remained status quo cab drivers and got what they got while this guy made a great living and became very unique in his industry.  He did so because he dared to be different…to fly solo.  What he did to be different wasn’t so unique in itself, but compared to what other cab drivers were doing it was incredibly unique.

If not taking risks is what people want to do, but it isn’t working, shouldn’t there be change.  Instead of looking only at services, software, processes, procedures and workflow that looks like everyone else, why not try something different?

I have heard over and over again when I talk to people about our EnrollmentCURE and EncounterCURE solutions “Our system handles that already”.  But those are most often the same systems that are installed by our Eagle-like clients who have worked with us to develop products that make major improvements in those areas.

The moral of this story is that we, in our complex healthcare industry, could very well be better positioned for success if we made the decision to pattern our business behavior after eagles instead of pigeons.