Managed Care - Current Challenges and Solutions

Written by Brent Murphy | Oct 18, 2019 4:00:00 PM

As I'm sure you are aware, both government and commercial payers agree the fee-for-service model is a broken system. It encourages providers to overuse costly diagnostic testing and treatments.

Deductibles and co-pays were designed to limit excessive use, but costs continue to rise. This is why everything is changing to a performance-based payment model. After all, the primary intent of managed care is to reduce health care costs. Emphasis on prevention of early detection and intervention. (treatment)

Are you ready for the changes?

1. You must make sure the claims you are making are supported by peer reviews and literature that demonstrates both clinical validity and utility.
Payment of claims is subject to utilization reviews in which the claim for services is scrutinized to determine whether the services were necessary. If during the review, the services are deemed unnecessary payment will be denied. The ability to show that you change the physician's decision-making process and intended treatment option is critical. This will enable you to present a compelling financial impact model showing significant long-term savings with the correct treatment option along with better patient care/outcomes and satisfaction. Starting a patient on the wrong treatment program is bad for the patient and very costly for the Payers.

2. In the new pay-for-performance value-based environment, you must be able to determine which patients are appropriate for your testing/services.
Patients must meet specific criteria to show the medical necessity.
Do not test and bill for patients that do NOT meet the requirements.
Try to eliminate retesting of previous patients this is a red flag to the Payers

You must scrutinize yourself through the use of ongoing training to make sure your message to the health care providers is accurate and consistent. This will help eliminate large patient balances and problems with the Payers. The quickest way to lose a large physician office group is if they start getting threatening letters and phone calls from the Payers about ordering your testing/services when the patient did not meet the appropriate criteria. Patient and physician satisfaction, as well as continuity of care, are critical components of diagnostics testing.

3. Payers consider most diagnostics testing a commodity. In today's managed care environment price is always going to be the driving factor. You must present yourself as a true partner to the Payers, helping them manage the cost of care for their patient population.
Now that we've established the importance of an effective managed care strategy, let's discuss the next steps to create an effective strategy. Some companies hire consultants, while others prefer a full-time managed care professional to create and implement an effective managed care strategy. Regardless of your preference, hiring a consultant or full-time person, the right person must be up to date on the new managed care regulations. Connexis Search Group has placed twenty-four managed care executives over the last four years. Companies that hire the right managed care professionals typically succeed, and those that do not fail.

Below are four critical factors you should consider when hiring a managed care professional:
› Proven success with value-based contracting.
› Documented long-term relationships with the Payers.
› The ability to work cross-functionally with your clinical and sales teams.
› Success with a previous company.

Now that you know the type of managed care professional you want to hire; how do you find them?
This is a search that you outsource to a professional recruiting firm such as Connexis Search Group. You need the services of a professional recruiter to pursue candidates that may not be actively looking for another opportunity. There are a limited number of diagnostics, managed care professionals, so posting these positions on Indeed or LinkedIn is futile. The best candidates also know that they do not have to look at job postings to find their next opportunity. They like working with recruiters who can tell them more about the opportunity and why they should consider your company.

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