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[Sanitized] Alternative Payment Methodology Product Process - Fortune 500 Company Presentation

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[Sanitized] Alternative Payment Methodology Product Process - Fortune 500 Company Presentation

  1. 1. Alternative Payment Methodology (APM) Process Overview 1 COMPANY ABC
  2. 2. APM Assessment (Shared Both in Division and Across Departments) Ensure Risk-based Contracts Have Appropriate Due Diligence to Minimize Risk Exposure Most Effectively. Ensure Process Does Not Bottleneck Existing “Processes” and Approvals are Streamlined. Ensure Appropriate Socialization and Change Management – Set Proper Expectations Ensure Proper & Appropriate Training Happens for Each Individual Involved in Process 2
  3. 3. • Organic Growth Process that Meets the Most Immediate Business Needs for the Market • Multiple value-based agreements already in place with hospitals/ACOs • Participation is primarily passive • Inventory and specific criteria still under assessment Current Environment (What Got Us Here?) 3
  4. 4. 4 Managed Care FFS Agreements ACO/CIN Agreements Regional contract Agreements (can vary by state and/or practice) Regional MC Manager or Director Regional VP or P Division MC Financial Analyst (East Division only for now) Division VP of MC Corporate Legal Division CFO or interim designee (Signatory) Regional MC Manager or Director Director of Ops Regional VP or P Division VP of MC VP of Quality and Safety CIO (only if there are technical requirements for data submission) Risk Management VP (if insurance limits are outside of pre-approved parameters) Corporate Legal Division CFO or interim designee (Signatory) Legal Practice Manager (for some anesthesia practices) DO RVP or RP, depending on the practice (Signatory) Current Approval Routing Process
  5. 5. 5 Value-Based Products (VBP) for Alternate Payment Methodology (APM) Approval & Roll Out - Overview VBP APM Product & Reimbursement Idea Sources Market COMPANY ABC Providers Regulatory Initial Assessment APM Committee Strategy Finance Operations Feasibility Design Quality & Safety Valuation & Modeling PMO / IT Final Product Selection Clinical & Financial Analytics Implementation Operational Readiness Clinical Readiness Quality Assurance Program Production & Review Quality & Cost Monitoring Performance Evaluation Reporting Payment Reconciliation APMRequestForm + + + = NoGoGo + + + +
  6. 6. VBP APM Product & Reimbursement Idea Sources 6 COMPANY ABD PD & R, Operations, Medical Services Market Employers, Brokers, Payors Providers Hospitals, Physicians, ACO/CIN Regulatory CMS, Medicaid APM Request Form COMPLETED
  7. 7. Strategy Internal Fit, Market Analysis, Partnership Alignment - President (NMG), CFO, Regional COO, President PD + R, COO PD + R - Finance Volume Drivers, Revenue Impact, Basic Cost Assumptions and Anticipated Margin -Division CFO’s - Operations Capability to Administer and Change Management Requirements - RP RVP - Feasibility Define Core Metrics, End Customer, Available Service Lines, Initial Practice Performance & Capabilities - CMO, VP Quality & Safety, Association Gov. Council - Initial Assessment PD + R / OPIs Alignment Committee 7 Go Initial Product Category & Decision Point (‘Go / No Go’) = No Go + + +
  8. 8. Quality & Safety Engage Medical Directors, Define Clinical Guidelines Measures, and Benchmarks Clinical and Financial / Underwriting Analytics Valuation & Modeling Proforma Final Product Selection Finance, Practice, Ops, PDR, Adv. Board Approvals and Drafting of Legal Agreement Design 8 PMO / IT Project Management Data-Warehouse Reporting Tools IT Infrastructure + + +
  9. 9. Operational Readiness Hospital Communication, Leadership, Prep and Training, Data Feeds, Testing, and Validation Set Clinical Readiness Physician Communication and Training (Change Management), Medical Director Role Definition, Clinical Pathways and Related SOPs Quality Assurance Program Develop Standard Reporting and Formats, Both Clinical and Financial, Internal and External. Set Recurring Meetings and Cadence for Internal and External Stakeholders. Implementation 9
  10. 10. Performance Evaluation Clinical and Operational Survey, Future Metric and Benchmark Setting, Stake Holder Feedback Reporting Clinical and Financial Accomplishments Relative to Selected Metrics and Benchmarks for the Participated Term Payment Reconciliation Validation and Settlement Funds Flow Distribution Production and Review 10 Program Quality & Cost Monitoring Monthly Clinical Indicators Performance Monitoring Monthly Financial Performance Random Data Sampling (% of Total) Data Mining for Key Drivers (Those with High Weight or Deterministic Value)
  11. 11. COMPANY ABC

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