Browse by Topic
Learn more about the healthcare finance industry's leading professional association. Find out why our members rely on HFMA as their go-to source for insight and information.
Members have many options for helping them advance their careers. Conferences, seminars, eLearning, certification, and more -- our education and events will keep you motivated.
On February 10-12, Physicians, Payers, and Providers will discover strategies for implementing value-based payment arrangements with both private and public sector payers.
Stay up-to-date in a rapidly changing industry in New Orleans (Mar. 7-9) or Chicago/Rosemont (Apr. 20-22). Register early and save.
Focus on the essentials. Develop strategies that deliver results. Redefine the boundaries of your success. Find out what’s driving innovation at ANI. Register by 2/29, save $150.
Our newsletters offer targeted articles with
technical how-to details and thought-provoking insights from healthcare finance
leaders and industry experts.
Get the perspectives of leading healthcare finance professionals on today's hottest issues.
Information about leading vendors helps your buying decisions.
Forum members can network during live webinars or access a library of past webinars on topics such as ICD-10 implementation, CMS audits, bundled payment, charity care, KPIs, and more.
An ever-expanding collection of spreadsheets, policies, job descriptions, checklists, and more that you can adopt and adapt.
Forum members can submit vexing questions to a panel of experts using our Ask the Expert service.
Your source for employment solutions.
Find new employment opportunities or
reach out to qualified candidates.
Distinguish yourself as a leader among your peers and advance your career by earning certification in our healthcare finance programs.
Get an objective third-party evaluation of products and services used in the healthcare finance workplace.
MAP App is a web-based application that helps organizations improve revenue cycle performance based on industry-standard metrics called MAP Keys.
Find suppliers and products in this comprehensive vendor directory for healthcare finance professionals.
Guidance for understanding and communicating about the price of health care.
Transformation toward value-based healthcare is reshaping the delivery of care, patient expectations, and payment structures.
Improve your revenue cycle performance through standard metrics, peer comparison, and successful practices.
Kaleida Health, the largest healthcare provider in the Western New York market, and BlueCross BlueShield of Western New York (BCBS), the region’s largest health plan, are blazing a trail that others will be expected to follow: They are lowering healthcare costs through a payer-provider partnership.
“We went into this knowing we have to find real, absolute cost reductions, and they need to be sustainable,” says Steve Swift, BCBS’s executive vice president and CFO.
Kaleida and BCBS formed a joint venture partnership called Kaleida HealthNow, Inc. that owns the new joint venture called Align. The health system and payer then recruited 500 physicians to form the Optimum Physician Alliance, an independent physician association that operates as a subsidiary of Kaleida HealthNow.
“One of the principles that we adopted at the outset is that this relationship has to be a four-way win: a win for the physicians, a win for the health system, a win for the health plan, and a win for the employers and insured members,” says Donald Boyd, senior vice president of network development and operations at Kaleida. “Otherwise, this will not be sustainable long term. That is the lens through which we do all of our work.”
Success factors include:
The plan launched in January 2013 when Kaleida and BCBS, both of which are self-insured, began offering it to their own employees. Later last year, the Blues began marketing it as a fully-insured plan to the commercial market. It is sold on New York’s public insurance exchange and will be offered on private exchanges in the future. In the first months of early enrollment on the New York exchange, about 40 percent of purchasers chose Align.
Developing an effective payer/provider relationship starts by identifying like-minded organizations in your market, Boyd says. “This is motivated by people coming together who believe that we have a responsibility to our community to build something that is going to be sustainable for the future,” he says. “If you have that as a guiding principle, it’s amazing what people can do in collaboration.”
With that perspective, payers and providers must stop arm-wrestling over unit costs and reimbursement rates, and work together to improve value, says Swift. “This is a fundamental mind shift in terms of the way we all are thinking about the business. We all must be focused on a collaborative win/win mindset as opposed to a win/lose.”
Believing that up to 30 percent of healthcare dollars are currently wasted, the partners are focused on eliminating unnecessary utilization, which would typically mean lower revenues for most specialists and health systems. However, Kaleida and the Optimum Physician Alliance expect to make up revenues with additional patients gained through the narrow network plan, which is attracting members with a lower premium and the promise of high-value providers (see the exhibit below).
The partnership moves reimbursement away from fee-for-service to pay-for-performance, with financial incentives based on physicians’ patterns of specialty referrals and generic prescriptions, their patients’ use of urgent care and the emergency department, and other metrics. Physician performance is evaluated each year to determine the provider network.
Kaleida and BCBS negotiated specific reimbursements for the Align plan. All profits created by the joint venture are shared equally by the two parties.
Boyd and Swift shared these tips on negotiating details of a narrow-network health plan:
Start with the end in mind. For Kaleida and BCBS, the goals were:
Recruit the right physicians. Kaleida and BCBS first recruited 15 independent physicians whom they knew to be value-minded to form a Physician Leadership Board.
“Forming this board was important because we wanted to hear from physicians who were independent and had choices in the marketplace,” Boyd says. “A lot of these conversations started with, ‘What are the challenges you’re facing? What ideas do you have about changing it?’”
The Physician Leadership Board is key to Align’s success because it identified the performance metrics needed to align physician incentives with those of the health system and the insurer. The Leadership Board was responsible for identifying 500 physicians—250 primary care and 250 specialists—to be in the Optimum Physician Alliance, and it is the entity that drives clinical integration. “We give them the authority and the responsibility to fulfill the set of objectives that we’ve established,” Swift says.
Those objectives are:
Collaborate. “This was a very collaborative, iterative process, whereby we met as a triumvirate of the physicians, the health plans, and the health systems to describe the different levers that we believed we could influence to deliver value to the community,” Boyd says. “And we worked to understand, quantitatively and qualitatively, how we would implement strategies that use those levers to deliver improved quality and reduced cost.”
“We met and worked regularly, team to team, for nine months,” Boyd says. The executive committee, comprised of C-level leaders, met every two weeks for two hours. In addition, payer-provider teams were assigned to develop specific aspects of the relationship, including clinical integration, legal and governance issues, the physician network, and data/analytics.
The teams shared information about each other’s operations and took part in new kinds of decisions. For example, the providers helped develop the benefit design of the new health plan.
“Historically, we would talk to customers and maybe to our broker partners to try to develop offerings that would meet their needs,” Swift says. “The thing that was really new about this is the fact that we had very explicit input from the delivery system.”
Based on early data from the health plan’s performance, Boyd is optimistic that the partnership is working as envisioned. The partners have agreed that, if any of the stakeholders are threatened financially by the arrangement, adjustments to the financial model will be made.
“There has to be an open-mindedness and willingness to try things because this is breaking new ground,” Swift says. “The recipe hasn’t been made, so there’s going to be some trial and error. We are going into this with that understanding.”
Lola Butcher is a freelance writer and editor based in Missouri.
Interviewed for this article:
Donald Boyd is senior vice president for network development and operations,
Kaleida Health, Buffalo, N.Y.
Stephen Swift is executive vice president and CFO, HealthNow New York Inc., the parent of BlueCross BlueShield of Western New York, Buffalo. BlueCross BlueShield of Western New York, a division of HealthNow New York Inc., is an independent licensee of the BlueCross BlueShield Association.
Either comment below or use the "inshare" button at the top of this web page to share this article and your comments on the Payment & Reimbursement Forum’s LinkedIn board.
Publication Date: Tuesday, January 28, 2014
TriMedx helps health systems control costs and uncover savings opportunities by optimizing the clinical engineering function.
Patient financial engagement is more challenging than ever – and more critical. With patient responsibility as a percentage of revenue on the rise, providers have seen their billing-related costs and accounts receivable levels increase. If increasing collection yield and reducing costs are a priority for your organization, the metrics outlined in this presentation will provide the framework you need to understand what’s working and what’s not, in order to guide your overall patient financial engagement initiatives and optimize results.
A leader from McKesson discusses how healthcare reform is forcing hospitals and health systems to take a different approach to capacity management and patient flow.
No two patients are the same. Each has a very personal healthcare experience, and each has distinct financial needs and preferences that have an impact on how, when and if they chose to pay their healthcare bill. It’s no longer effective to apply static billing techniques to solve the complex challenge of collecting balances from patients. The need to tailor financial conversations and payment options to individual needs and preferences is critical. This presentation provides 10 recommendations that will not only help you improve payment performance through a more tailored approach, but take control of rising collection costs.
Emad Rizk, MD, president and CEO of Accretive Health, discusses the uncertainty facing hospitals and the transitions affecting revenue cycle management.
This white paper, written by Apex Vice President of Solutions and Services, Carrie Romandine, discusses the importance of patient segmentation and messaging specifically related to the patient revenue cycle. Applying strategic messaging that is tailored to each patient type will not only better educate consumers on payment options specific to their billing needs, but it will maximize the amount collected before sending to collections. Further, targeted messaging should be applied across all points of patient interaction (i.e. point of service, customer service, patient statements) and analyzed regularly for maximized results.
Jim Bohnsack, vice president, solution & corporate development for Conifer Health Solutions, explains how the company helps healthcare providers leverage data to deliver better outcomes while optimizing reimbursement for all payment arrangements.
This white paper, written by Apex President Patrick Maurer, discusses methods to increase patient adoption of online payments. Providers are now seeking ways to incrementally collect more payments due from patients as well as speeding up the rate of collections. This white paper shows why patient-centric approaches to online payment portals are important complements to traditional provider-centric approaches.
Steve Scibetta, senior director of channel sales for Ontario Systems' healthcare product line, shares insights into effectively managing receivables.
Increased electronic engagement between healthcare providers and patients provides significant opportunities for improving revenue cycle metrics and encouraging patients to access EHRs. This article, written by Apex Founder and CEO Brian Kueppers, explores a number of strategies to create synergy between patient billing, online payment portals and electronic health record (EHR) software to realize a high ROI in speed to payment, patient satisfaction and portal adoption for meaningful use.
Elena White, vice president of risk, quality, and network solutions for Optum, discusses how healthcare providers can leverage data and technology as they enable risk in their organization.
Faced with a rising tide of bad debt, a large Southeastern healthcare system was seeing a sharp decline in net patient revenues. The need to improve collections was dire. By integrating critical tools and processes, the health system was able to increase online payments and improve its financial position. Taking a holistic approach increased overall collection yield by 10% while costs came down because the number of statements sent to patients fell by 10%, which equated to a $1.3M annualized improvement in patient cash over a six-month period. This case study explains how.
Somnia President and CEO Marc Koch, MD, MBA, explains how hospitals can drive transformative change in the perioperative experience for outstanding clinical and financial outcomes.
With the ICD10 deadline quickly approaching and daily responsibilities not slowing down, final preparations for October 1 require strategic prioritization and laser focus.
PMMC President Roger L. Shaul discusses the effects of healthcare reform on revenue cycle management and how PMMC's products help clients adapt to a changing financial environment.
Read how Gwinnett Medical Center provides clear connections to financial information, offers multiple payment options for patients, and gives onsite staff the ability to collect payments at multiple points throughout the care process.
Greg Burgess, Founder and Chief Product Officer at Burgess Group shares insights and opportunities for payment integrity in the rapidly changing healthcare IT landscape.
Read how Orlando Health was able to perform deeper dives into claims data to help the health system see claim rejections more quickly–even on the front end–and reduce A/R days.
To maintain fiscal fitness and boost patient satisfaction and loyalty, healthcare providers need visibility into when and how much they will be paid–by whom–and the ability to better navigate obstacles to payment. They need payment clarity. This whitepaper illuminates this concept that is winning fans at forward-thinking hospitals.
Financial services staff are always looking for ways to improve the verification, billing and collections processes, and Munson Healthcare is no different. Read about how they streamlined the billing process to produce cleaner bills on the front end and helped financial services staff collect more than $1 million in additional upfront annual revenue in one year.
Effective revenue cycle management can be a challenge for any hospital, but for smaller providers it is even tougher. Read how Wallace Thomson identified unreimbursed procedures, streamlined claims management, and improved its ability to determine charity eligibility.
Before launching an energy-efficiency initiative, it’s important to build a solid business case and understand the funding options and potential incentives that are available. Healthcare leaders should consider taking the steps outlined in the whitepaper to ease the process of gaining approval, piloting, implementing, and supporting sustainability projects. You will find that investing in sustainability and energy efficiency helps hospitals add cash to their bottom line. Discover how hospitals and health systems have various options for funding energy-efficient and renewable-energy initiatives, depending on their current financial structure and strategy.
Health care is a dynamic mergers and acquisitions market with numerous hospitals and health systems contemplating or pursuing formal arrangements with other entities. These relationships often pose a strategic benefit, such as enhancing competencies across the continuum, facilitating economies of scale, or giving the participants a competitive advantage in a crowded market. Underpinning any profitable acquisition is a robust capital planning strategy that ensures an organization reserves sufficient funds and efficiently onboards partners that advance the enterprise mission and values.
The success of healthcare mergers, acquisitions, and other affiliations is predicated in part on available capital, and the need for and sources of funding are considerations present throughout the partnering process, from choosing a partner to evaluating an arrangement’s capital needs to selecting an integration model to finding the right money source to finance the deal. This whitepaper offers several strategies that health system leaders have used to assess and manage capital needs for their growing networks.
Copyright 2016, Healthcare Financial Management Association.
Join HFMA today and enjoy: