Value based contracting is more than just an industry buzzword. It is quickly becoming the new normal for providers of all sizes and for all types of contracts.
Wakely can perform actuarial certification for the Knox-Keene licensing requirement in California.
The California DMHC adopted new regulation that defines various types of risks that entities assume, including health care providers, and establishes that any entity assuming “global risk” must obtain a Knox-Keene license or receive an exemption. Wakely has the experience and expertise to develop the actuarial components of the required licensure application pro forma. For more information click here: https://www.wakely.com/blog/california-raises-bar-risk-bearing-entities
Shared Savings and Risk Support
The Centers for Medicare and Medicaid Services (CMS), along with traditional insurers, are increasingly seeking to engage providers in value based risk relationships. This goal aligns incentives – reducing the cost of care while providing a better patient experience and improving the health of the population - between payer and provider and offers sophisticated providers an opportunity to earn shared savings. Wakely partners with providers to ensure they are prepared to bear financial risk, understanding the levers for financial success, and ensuring that their payer partnerships do not include any unintended consequences, within or between the various agreements in which they are participating.
To support their success in these agreements, Wakely will assist providers in analyzing their assigned populations by cost, utilization, and disease state to help them focus their population health efforts on sub-populations that can benefit the most from intervention. Regular population health and financial reporting can help providers track success in clinical interventions, identify areas of improvement, and support strategic initiatives for future contract participation.
Alternative Payment Model Consulting
CMS and the Center for Medicare and Medicaid Innovation (CMMI) are actively looking for pathways to improve patient care while encouraging cost-effectiveness. This includes delivery models like CMS’ Medicare Shared Savings Program (MSSP), and CMMI’s Next Generation ACOs (Accountable Care Organizations) and Bundled Payments for Care Improvement (BPCI) models. Providers can participate in ACOs and realize greater potential for both risk and reward with the goal of providing better patient engagement and health outcomes while striving to achieve a lower cost than original Medicare Fee-For-Service. ACOs realizing these goals can share in the cost savings achieved, while unprepared ACOs can suffer financial losses. Wakely’s actuaries partner with interested providers and ACOs through the entire lifecycle of these models. Our experts will support ACO efforts to project performance and the ultimate benchmark against which performance will be measured, identify variations in care among the provider panel, and develop strategy and tactics for effective population health management, including risk adjustment optimization.
Medicare Access and CHIP Reauthorization Act
Medicare Access and CHIP Reauthorization Act (MACRA) is in effect now and will impact the majority of providers that accept Medicare patients. Providers can choose to participate in an Advanced Alternative Payment Model (APM) (e.g. MSSP tracks with downside risk, Next Generation program, etc.) or participate in the Merit-Based Incentive Payment System (MIPS). There are significant implications to provider organizations in terms of reporting requirements and reimbursement impacts under both tracks of this program.
Wakely’s actuaries will work with provider organizations to determine their potential financial impacts under MACRA and help develop strategies for success under either an advanced APM or MIPS track.
Provider-Sponsored Health Plan Support
Provider-sponsored health plans (PSHPs) have different considerations than traditional issuers, whether they offer commercial insurance plans, Medicare, or managed Medicaid. To be successful, they require experts familiar with the nuances they face. Wakely’s expert team can help PSHPs think through their approach to network configuration and transfer pricing between health plan and provider system. In addition, our actuaries can also provide support for traditional areas of practice like product pricing and strategy, trend driver identification, reserving, and support for quarterly and annual financial statements.