Key Components in Shared-Risk Pool Reporting

When a team works well together, the members collectively accomplish more than any of the individuals could have accomplished alone. Certainly we have proven that adage true in healthcare as can be seen with the success of integrated delivery systems, Independent Physician Associations (IPAs) and Accountable Care Organizations (ACOs), as well as providers teaming up with other providers on initiatives such as the bundled payment program. As health plans continue adapting to the growing influence of clinical/quality and value-based care and reimbursement, building an effective patient management workflow along with financial reporting systems between plans and providers engaged in risk arrangements has never been more important.

In order to effectively manage risk dollars we have to first manage our patients in real time. We need to continue to strive towards effectively managing where our patients are at a particular point in care, what services they are currently receiving and by whom, and what their next step is in the care continuum. It is a balancing act in juggling disparate electronic health records (EHRs), an outcropping of new vendors, and community-based services providers who are new to managed care. While we continue to put patient care first, against a backdrop that still has not found the perfect solution, we need to design and implement metrics that can be meaningful and measurable to ensure the care solutions we are implementing are working clinically while reducing the total cost of care over our population.

The key components to any successful risk-based or percentage of premium contract are transparency and timeliness in reporting. Without transparency, there can be no trust in the relationship, and without timely reporting, we are unable to elicit change in a meaningful time frame. Effective management reports prepared on a periodic basis should address provider budgets versus actual performance under risk-based agreements. Baseline items to review are:

  1. Allocation (Revenue)
  2. In-Network Claims
  3. Out-of-Network (OON) Claims
  4. Incurred But Not Reported (IBNR)
  5. Reinsurance and Stop Loss
  6. Per Member Per Month (PMPM) Budget
  7. Administrative Charges/Fees

In addition to the above, plans and providers should have a clear delineation of financial responsibility, contract terms, operational items such as authorization process, and all state and federal compliance requirements. As relationships develop and expand over various populations and lines of business, your reporting models should be consistent, scalable, and reduce the administrative burden on the providers. At the same time, with the continued issue of data integrity, shared risk is also a perfect time for providers to step up and support their health plan partners by providing current provider and practice information. The improved member satisfaction that comes with correct information will be a win-win for both sides.

At Gorman Health Group, we can provide the cross-functional expertise you need to help your health plan team and providers be exceptional.



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