managed care services
Aspire Integrated Healthcare is a high-performance healthcare management and consulting company with 30 years’ experience in Managed Care, Healthcare Operations, Technology Solutions, and Provider Payment Strategies. Our Vision is to improve the healthcare system by creating a more efficient, cost effective, clinically focused delivery system with our creative process improvements, efficient management, and innovative technology solutions.
We currently manage nationally over 20 hospitals, we have opened 10 new hospitals, and other provider types, totaling over 1,000 contracts and credentialing over 300 hundred providers with all Payer types (commercial, MCO’s, Medicaid, Medicare). We have developed and managed provider networks for United Healthcare, Scott & White Health Plan and our own Aspire High-Performance Provider Networks on a local, statewide, regional or national scale.
Managed Care Services
The Aspire Healthcare Consulting team develops, analyzes, negotiates, and manages payer contracts, terms, and provider payment structures for any type of Healthcare Provider (Hospitals, Physicians or Ancillaries), Health Plan, Employer, ACO, Network, TPA or related business. Our pricing options are customized to ensure our clients have a significant return on their investment. We offer flexible options to our clients as a service that supports your contracting or managed care team, or we can be your Managed Care Director or Payer Contracting Manager.
Our highly experienced team members facilitate contract negotiations, conduct legal and financial analyses to determine the feasibility of each managed care contract and reimbursement terms. We also provide additional contracting support, direct employer contracting services, technology solutions, contract performance monitoring, contract management, workflows for the contract approval process and credentialing services.
strategy
We will work with our client to develop a customized strategic plan and Managed Care System or “MCS” is the system that provides for the coordination of all functions related to the reimbursements received from Payers and the alignment with them. We group each function of the MCS into the following categories: a) alignment, relationship, collaboration, b) contracting, c) credentialing, d) medical management, and e) revenue cycle management.
Payers are defined as any entity that is the source of financial payment for medical services rendered by any healthcare provider or delivery system. We group each Payer by product type: a) Commercial b) Medicare c) Medicaid d) Tricare-Military. Our goal is to establish the Managed Care System “MCS” successfully and profitably to optimize the reimbursements, increase authorizations and decrease denials from all Payers at all locations.
The MCS coordinates and manages all functions related to these goals. As a result of these operations and process improvements, we hope to achieve an increase in our reimbursements from all Payer sources system wide; the assessment process will indicate percentage increase goals.
payer-Provider contracting
The Managed Care contracting process is our system which provides for the coordination of all functions at the corporate office and each facility (contracts, rates, fee schedules, credentialing, payer policies, compliance, performance measures, etc…) related to the maximization of reimbursements received from all Payers. A Payer is defined as any entity that is the source of financial payment for medical services rendered by any healthcare provider or delivery system, such as Managed Care Organizations (HMO, PPO, ACO, IPA), Insurance Carriers, Self-Insured Employers, Risk Pools, or Governmental Entities (Medicare, Medicaid, Tricare, Counties, Courts).
technology
Our Technology partners power our ability to be highly effective in our Managed Care Services.
We have partnered with the Sapphire Software Solutions that improve our client's cash flow and third-party payer reserve objectives by providing managed contract modelling and payment analytics resources that includes the following:
1. Data Analysis to identify revenue opportunity from Payers
2. Payer Contract management tool
3. Payer Fee Schedule tool
4. Revenue Cycle Management solution
network development
Aspire Integrated Healthcare provides healthcare network development, management, and strategy services on a national scale for payers, employers, networks, and other healthcare purchasers. We are interested to be your long-term partner to develop and manage your healthcare provider networks. We offer a variety of options that our clients can chose from.
We partner with each client to develop and manage their own healthcare provider partnership network that integrates and applies healthcare information between Employers, Providers, care teams and payers with high-performance, high-quality outcomes and cost savings initiatives.
We help Providers and care teams to focus on early detection, prevention, wellness programs, disease management, and post-discharge programs that reduce hospital admissions, readmissions and much more. We help Providers to deliver both lower costs and higher quality through care that is patient-centered, evidence-based, appropriate, and coordinated care which include the following Triple Aim goals:
- High-Performance, Integrated Healthcare Providers that are collectively accountable for the entire continuum of care for the entire Employee population, overall costs, and quality of care for Employee’s.
- Provider payment models that reward Providers for quality improvements and slow spending growth, while avoiding excessive new financial risk for Employers, and
- Reliable performance measurement to support improved health outcomes and lower costs that are achieved with better care.
Provider Network Design and Development
We have designed a highly efficient Provider Network Development and Management process for a local or large-scale network with the ability to manage thousands of provider managed care contracts. Our Provider Selection process is determined by each client with our expert advice which includes the most current industry standards and regulatory compliance to ensure the highest quality Providers are selected and that they continue to maintain this level of performance. We will assess the established and targeted geographic service areas to determine panel adequacy requirements and industry standards to provide the highest quality of medical care to current or potential Members. Employers to have network Provider access options such as: Tiered Narrow Networks based on quality, cost or other measures, Patient Centered Medical Home or Primary Care gatekeeper, access to a wrap PPO Network and other options.
Provider Reimbursement Models (Value Based Care)
Providers are contracted based on their quality performance using the nationally recognized Provider Performance Incentives adopted by Medica, which include the Medicare Hospital Value-Based Purchasing (VBP) Program, Medicare Physician Quality Payment Program and the American Association of Family Physicians. Additional customize Value Based Contracts or incentive programs including pay for performance, shared savings (upside risk), shared risk (downside risk), episodic/bundled payments, and capitation/global payments. Our objective is to lessen the burden on our Providers by adopting these current VBC programs they have with other Payers. We have adopted the following Medicare Physician Quality Payment Programs and we may adopt additional VBC models based on the Providers unique situation to meet our High-Performance Network goals for our Employers. We can help our clients to design the optimal provider reimbursement model:
- Risk share arrangements
- Value Base Care model including Pay for Performance, Alternative Payment Models, Bundled Payments and more!
- 3. Fee For Service
Quality Performance Standards
Robust data-sharing and effective quality measurement play a critical role as well in identifying providers delivering quality care at a lower cost. Quality standards for our Networks are well-defined, rigorous, and derived from sufficient data in order to drive performance delivering quality outcomes and make a substantial impact on health care spending. We follow the Medicare, NCQA HEDIS and American Association of Family Physicians “AAFP” guidance on quality measure programs for our Providers. The Quality Improvement Program “QIP” is comprehensive and shall be continuously maintained to monitor and evaluate the quality and appropriateness of clinical care and services, and to pursue opportunities for improvement objectively and systematically. This specifically includes development and oversight of the medical case management an all programs, services, and policies. Aplos utilizes the nationally recognized and evidence-based quality improvement program by URAC and Medicare CAHPS
Direct Provider Medical Arrangements
Another contracting option is the Employer Direct Medical Arrangement option which provides an alternative to traditional FFS-based primary care models, and it improves the patient-doctor relationship, reduces the fragmentation of patient care, and improves both personal and professional satisfaction for physicians. This alternative primary care arrangement generates systemwide reductions in health care utilization including hospitalization rates, emergency department usage, unnecessary radiology and diagnostic tests, and specialist care, leading to broad-based health care cost savings. Advantages of the Employer Direct to Provider are according to the study by Society of Actuaries a) reduces unnecessary healthcare services over 12%, b) reduces Emergency Room visits over 40%, and c) reduces unnecessary Hospital admissions by 20% or more!
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