MANAGED CARE CONSULTING SERVICES

Transcription

1 CONSULTING SERVICES WeiserMazars Health Care Consulting Services THE NEW JERSEY HOSPITAL ASSOCIATION April 30,2013 WeiserMazars LLP is an independent member firm of Mazars Group.

2 WEISERMAZARS HEALTH CARE GROUP The WeiserMazars Health Care Group offers health care providers a powerful combination of service and results-oriented strategy to help clients meet their business goals, overcome challenges, and improve performance. With decades of experience in the health care industry, we are more than just competent technical resources we provide timely, valuable information and insights into policies, best practices and industry developments. We are committed to providing value-added services from audits and feasibility studies to information technology consulting, managed care consulting, and revenue cycle management. Because we have served as C-suite executives at, or provided close consultation to, many hospitals and medical facilities throughout the United States, our team offers a unique level of insight into client needs and best practices. This depth of expertise gives us a level of resources usually found in larger consulting and accounting firms while allowing us to give clients a higher level of value and individual attention. Our services now cover all key areas needed by clients in this time of volatility and industry-wide change: Financial Advisory Services IT Consulting Managed Care Consulting Revenue Cycle Management WeiserMazars LLP is an independent member firm of Mazars Group.

3 CONSULTING SERVICES WeiserMazars LLP: Exactly Right. Creative Health Concepts Group As one of the nation s leading accounting and consulting firms, WeiserMazars provides the resources, experience and global expertise to help you adapt in a dynamically changing business landscape. January 2014 will see major provisions of health care reform implemented under the Patient Protection and Affordable Care Act. All aspects of the health care delivery system will need to be substantially transformed in under a year. As the paradigm shifts from procedure-based to value-based, Managed Care approaches will become essential. As a leading change facilitator in this era of sweeping health care reform, WeiserMazars provides a full-service consulting offering to health care providers of all types. Through a merger with Creative Health Concepts Group, a boutique health care consulting firm, we have gained a dedicated team of professionals highly specialized in providing managed care related services to payers, providers and private equity firms. With over 30 years of experience in serving the health care industry, we offer a wide range of high-performance solutions for both government and commercial clients. Key clients include payers such as VNSNY CHOICE, WellCare Health Plans, Emblem Health, POMCO Group, Affinity Health Plan, and CenterLight Health System. On the provider side, we have significant experience working with hospitals, health systems, physicians, and multi-specialty groups. We have an especially deep background in Government Programs, Medicaid, Medicare and Managed Long Term Care. Our services include: Network development Contract negotiations Credentialing of physicians, ancillary services ACO development Executive search Out-sourced managed care services Strategy, development and implementation for building turn-key payer networks Developing strategies for creating reimbursement claims across all health care product lines Reimbursement methodologies/capitation fee for service Private equity offerings Payer and provider quality improvement, HEDIS scoring Benefits of our services: Negotiate effective managed care contracts for both providers and payers Provide outsourced managed care services for providers Develop and implement turn-key payer networks Analyze quality and clinical outcomes for providers and implement improvements Provide managed care expertise in developing strategies to improve reimbursement 2

4 PAYOR NETWORK DEVELOPMENT & CONTRACTING Enactment of the Patient Protection and Affordable Care Act promises to fundamentally change the way health care is delivered in America. Keeping track of the changes, interpreting new rules and regulations, and correctly predicting their impact will be critical in ensuring your organization s success. Supporting payors in achieving their provider contracting goals is one of our core competencies. We help you with: Network analysis through data mining of proprietary and public databases to ensure key providers are contracted and competitive networks are built. Claims data analysis, used for benchmarking, contract modeling, identifying utilization trends, detecting high cost providers and/or services. Negotiations to attain the most advantageous contract rates and language provisions PAYOR TYPES HMOs, PPOs, TPAs, ASOs National or local market organizations Medicaid, Medicare Advantage, Commercial, Worker Comp and No Fault NETWORK DEVELOPMENT SERVICES Introduction into new markets and territories Product expansion into existing markets Expansion of existing markets to meet competitive landscape Development of cost effective network options CONTRACTING MODELS Fixed rate fee for service Risk Pay for performance insurers nationwide including HMOs, PPOs, FFS, Workers Comp and No Fault, Behavioral Health and other specialty networks using: Percentage off charges Case rates per diems with or without carve-outs Flat rates for technical and/or professional components In-patient/outpatient charges in conjunction with hospital Fee-for-service contracting Primary care physician capitation Full or partial risk contracting Pay for performance NETWORK DEVELOPMENT PROJECTS BY TYPE: ANCILLARY CATEGORIES Another core product is network development and contracting for Medicare Advantage and Commercial 3

5 PHYSICIAN PRACTICE & ALIGNMENT SOLUTIONS The Affordable Care Act had a major impact on Medicare Advantage Plans in Many of the law s provisions are slated to be implemented in January These changes to the existing system could lead payers into a number of pitfalls when marketing Exchange products to individuals without specific individual claims data available. Community rating will lay the foundation for the way actuaries will forecast claims and also be a platform for establishing the premiums that payers will receive from State and Federal subsidies. This will create a subset of the uninsured and underinsured population with potentially higher risks because of the lack of medical history. WeiserMazars extensive experience with Physician Practice and Alignment Solutions allows us to assist both voluntary and employed hospital physicians with: Physician contract negotiations with payors FFS, risk and gain sharing reimbursement Pay for performance reimbursement Aligning and enhancing relationships with medical staff Sharing the same vision for both hospital and physician leadership Assisting hospital management in billing, training of employees, scheduling and purchasing Practice management and interface with physician leadership Practice acquisition Physician credentialing with payors Practice and program development Cost effective and high quality of care Physician interface with IT systems Physician incentives Facilitating electronic medical records Outsourcing executive management for multispecialty group practices 4

6 ACO ASSISTANCE AND DEVELOPMENT OF PROVIDER ALIGNED SOLUTIONS Proposed Federal regulations would impose 65 quality measures that ACOs must meet in order to share in savings with the Federal Government, fitting into two separate tracks with differing mixes of risk and savings. Private sector ACOs are already struggling to navigate the business decisions needed to set up these entities while HHS regulations governing ACOs create new challenges for Medicare providers. WeiserMazars can assist Provider Organizations with solutions and products to enter the ACO Movement. Strategic analysis & demographics Provide assistance in developing sustainable relationships between hospitals and physicians Interface with joint leadership in creating common goals Develop and ensure network adequacy for ACO entity Assist in payor contracting activities Align hospitals & physicians with common interests Recommendations of shared governance Establishment of system infrastructure to support care management Solutions for cost and quality metrics Establish customer service platforms for patients Executive staffing Credentialing Coding & documentation* * Changes due to healthcare reform require a transformation of how hospitals and providers review EMRs and encounters. We have a solution... CHC Coding & Documentation 5

7 PRIVATE EQUITY HEALTH CARE CONSULTING SERVICES MANAGED CARE January 2014 will see major provisions of health care reform implemented under the Patient Protection and Affordable Care Act ( ACA ). All aspects of the health care delivery system will need to be substantially transformed in under a year. It is expected that over $2.8 trillion will be spent on health care in the year that ACA comes into full effect. This significant spending has attracted large amounts of Private Equity investors. In 2012 alone, over $4 billion was invested in health and medical service companies - with many firms seeking additional investment opportunities. As a leading change facilitator in this era of sweeping health care reform, WeiserMazars provides a full-service consulting offering to health care providers of all types. Through a merger with Creative Health Concepts Group, a boutique health care consulting firm, we have gained a dedicated team of professionals highly specialized in providing managed care related services to payers, providers and private equity firms. With over 30 years of experience in serving the health care industry, we offer a wide range of high-performance solutions for both government and commercial clients. Our services include: Improve top-line revenue Establish distribution channels Expand service lines Due Diligence Risk reimbursement arrangements Restructure contracting departments Retained Search Develop storyboards Assist in directing clients to access to capital Develop comprehensive Medicare/Medicaid pricing strategy for acquired products Represent products during insurance company coverage approval process Benefits of our services: Dedicated team of healthcare professionals with over 30 years of Insurance/Managed Care solutions Access to key payers and insurance companies Negotiation of effective contracts Provide expertise in developing improved reimbursement strategies Medicare/Medicaid reimbursement experience 6

8 RETAINED EXECUTIVE SEARCH The dynamics of the current health care business environment have prompted many organizations to aggressively recruit seasoned and tested executive staff. These organizations know that they face significant, immediate challenges in a number of operating arenas. Their need for skilled teams to confront the issues has never been more urgent. Growth can also impose new requirements that cannot be met without added infrastructure and/or new expertise. Creative Health Concepts of WeiserMazars focuses on serving the needs of the health care industry. Through our extensive consulting network, we have been able to develop a track record of locating and recruiting successful executives from inside and outside the health care ranks. The Case for a National Search Integrator While most executive search engagements are singlesearch assignments, organizations occasionally require a coordinated, multiple market/multiple job campaign. When planning a multiple market search campaign, a client can independently implement any or all of three possible methodologies: I. Local scouting, conducted sans search firm assistance using referrals and/or advertisements II. Multiple, single-assignment search firm engagements, premised upon local expertise III. A regional/national search campaign, managed by one, experienced search firm. We are uniquely suited to qualifying top rank candidates for our clients. We invest the time to learn the clients values, capabilities and career requirements. We are committed to personally examining the candidates recommended so as to assure that you meet only the most qualified people. Creative Health Concepts of WeiserMazars began as an executive recruitment firm before moving into consulting, but has always maintained its extensive executive search capabilities. 7

9 Search Methodology Typically our clients critical need for fast and zero-defect hiring puts pressure on the process of search firm-based candidate evaluation and assessment. We presents candidate finalists who routinely exceed the expectations of hiring managers. To meet a client s special needs, we deploy our principals as the seasoned vetting team for final candidates. Our arduous process ensures that each candidate referral meets our standards and exceeds yours. We have developed a multi-tiered search process which assures that our clients consistently receive thorough and effective service. We customize the process to the specific needs of each client and search campaign, while maintaining a rigorous methodology. INTERIM MANAGEMENT Creative Health Concepts of WeiserMazars Retained Search Team served health care companies by placing quality leaders into hospitals and payor organizations for over 30 years. We recognize that recruiting the right fit candidate for a permanent position is time consumingand the importance of maintaining operational continuity. Our team of experienced professional consultants will help keep your organization running smoothly during the search process. We maintain a cadre of experienced Interim Executive Managers who create immediate impact for the institutions theyserve. Our consultants have wide-ranging experience across the health care continuum, having served in numerous executive positions with full P&L responsibility. Our expertise includes operations, compliance, and quality. We are skilled in process improvement, problem solving, and project management. As interim managers at hospitals and payor organizations, we analyze organizational priorities, develop action plans, and implement performance improvement strategies while managing new initiatives to increase productivity and efficiency. We will assess key staff, address opportunities within a department, assist in training and develop benchmark goals. 8

10 OUR TEAM Ira Gottlieb Principal Ira has spent over 30 years in the managed care market segment on both the provider and payer sides. He delivers professional, effective managed care consulting advisory services to national, regional and local insurance and managed care plans. Ira s diverse clients include hospitals, hospital systems, physicians, multi-specialty groups, ancillary services and Private Equity Groups that have healthcare-related portfolio clients. Many of his client relationships extend back over 20 years. Prior to joining WeiserMazars, Ira was the founder and Chief Executive Officer of Creative Health Concepts (CHC), which he established as a market leader in the healthcare industry. Ira has substantial experience working with client organizations entrenched in the government programs space. He develops strategy and systematic approaches to assist payers in developing turn-key provider networks for Managed Medicaid, Managed Medicare and Managed Long Term Care Plans. In addition, Ira provides out-sourced managed care services to select hospital and hospital systems within the Metro- New York marketplace. He also served as an executive search consultant within the healthcare industry, providing C Suite executives while developing a comprehensive understanding of industry needs. CONTACT 135 West 50th Street New York, NY Ira.Gottlieb@WeiserMazars.com 9

11 Debra E. Bornstein Principal Debra has more than 20 years experience years in healthcare with a concentration in building and maintaining diverse provider networks for some of the largest managed care organizations in the New York tri-state area. Her expertise lies in provider contracting, strategic planning, medical cost trending and operational transaction management for HMOs, PPOs and TPAs. Prior to joining WeiserMazars, Debra was the Chief Operating Officer of Creative Health Concepts (CHC). She oversaw all aspects of CHC projects to ensure effective business processes, operational infrastructure, profitability and growth. She supported the company s core service offerings including: payer contracting, network development, pay-for-performance management and provider credentialing. Debra has also been a Market Head at Aetna; Vice President of Medical Delivery Systems at MagnaCare; Vice President of Health Services at United Healthcare and; Director, Medical Delivery at Oxford Health Plans. Debra earned her BS in Economics and Business from Millersville University. CONTACT 135 West 50th Street New York, NY Debra.Bornstein@WeiserMazars.com 10

12 CONTACTS Ira Gottlieb Principal, Health Care Group Debra Bornstein Principal, Health Care Group About WeiserMazars Since 1921, WeiserMazars LLP has provided a unique combination of foresight and experience when fulfilling client needs in accounting, tax and advisory services. Named a top U.S. accounting firm by Accounting Today in 2012, WeiserMazars team of professionals brings technical expertise, industry insight and an integrated, customized approach to dealing with the critical issues and competitive challenges facing the firm s clients. Whether on the local level or internationally, the firm guides clients through their day-to-day operations and works with them to ensure they have the right financial structure in place to meet their business goals. WeiserMazars team of over 100 partners and approximately 700 professionals is based out of six U.S. offices, Israel and the Cayman Islands. As the independent U.S. member firm of the Mazars Group a prominent international accounting, audit, tax and advisory services organization with over 14,000 professionals in more than 70 countries on six continents WeiserMazars represents clients of all types, including owner-managed businesses, complex, multi-national organizations and high net worth individuals in a multitude of industries. Visit us on Follow us on WeiserMazars LLP is an independent member firm of Mazars Group.