Blog

Over the past few years, we have continued to see an increase in provider clients interested in pursuing not only global risk but specifically capitation. This interest has accelerated with the COVID impacts on fee-for-service (FFS) visit revenue as well as the former Medicare Direct Contracting and current REACH ACO programs from CMMI which include […]

As the market continues its transition nationally towards value-based care, risk shifts from health plans to providers.  A big part of this shift means providers own and operate functions and services traditionally handled by health plans, such as utilization and care management, credentialing, claims processing, network development, technology support and more. Faced with the need […]

Shared savings programs do not prepare independent physician associations (IPAs), clinically integrated networks (CINs), and other providers to take on full population health management and corresponding actuarial risk. One important window into understanding how to move forward with full risk is Medicare Direct Contracting, the predecessor to the Centers for Medicare & Medicaid Services’ new […]

The New York State Medicaid Redesign team has made a formal request to the federal government for a $13.52 billion investment over five years, starting on January 1, 2023, to continue to fund new amendments to its 1115 Waiver Demonstration. This will address the health disparities and systemic health care delivery issues that have been […]

To successfully move from fee-for-service to global risk, health plans and providers need a new contracting playbook. At a high level, the ground rules for value-based contracting should include: Providers should take the time to establish clarity on what they want and, whenever possible, provide their payer partners with 1-to-3 year deal points frameworks to […]

Rather than take on too many delegated responsibilities at once, some physician organizations adopt a hybrid model: They assume medical management while continuing with the health plan’s contracted network, and the plan continues to pay claims, providing reports to the medical group. But this arrangement can lead to critical data gaps because provider agreements require […]

COPE Health Solutions and its Analytics for Risk Contracting, LLC (ARC) subsidiary have launched the first health analytics platform and solutions that integrate a health care organization’s claims, electronic health records, lab, social determinants and other data with CareJourney’s suite of cost and utilization benchmarks derived from Medicare and Medicaid datasets. The solution enables providers […]

To reduce the administrative burden for providers and improve patient care, the federal government is considering creating electronic standards for prior authorization. In a process that ended March 25, HHS’ Office of the National Coordinator for Health Information Technology (ONC) solicited comments on electronic prior authorization standards, implementation specifications and certification criteria that could be […]

Health care providers have a narrow window to decide to take advantage of the newest alternative payments program from the Center for Medicare and Medicaid Innovation (CMMI). Just two weeks ago, CMMI announced it is replacing the Medicare Direct Contracting program with the ACO Realizing Equity, Access, and Community Health (ACO REACH), an accountable care […]

California is staking out bold new requirements for commercial health plans interested in providing managed care services for Medi-Cal, the state’s Medicaid health insurance program for low-income children, adults and seniors. Up for grabs are contracts to provide Medi-Cal coverage in 33 of 58 California counties and for 38% of the state’s Medicaid population. Roughly […]