Health plan implements solutions for ACO contract administration with Baker Tilly

The Business challenge

Our client was aggressively pursuing a network strategy of negotiating ACO Shared Savings arrangements with Integrated Health Systems in their network. Their goal – to promote financial risk sharing and alignment of incentives with the delivery of improved quality care to members while lowering the cost curve. Many of the business processes and systems needed to achieve these changes did not exist.

  • Organization structures, roles and responsibilities: The implementation of ACO agreements required integrating impacted departments in very different ways from what was needed for a traditional fee-for-service model – creating a critical need to define new roles, responsibilities, and processes.
  • Legacy systems and processes: In order to achieve the scale desired as ACO arrangements grew through the network, the introduction of new technologies and the integration of new and existing technologies was a necessity.
  • A new experience: Client was operating in an environment where the details were constantly evolving, the demands of the business focused on rapid delivery to keep up with the market, and “best practices” did not yet exist. The number of health systems entering into these agreements was increasing every six months, In addition, the client was dealing with many other projects driven by regulatory and compliance changes currently impacting the industry.

The Baker Tilly solution

Baker Tilly provided program and project management guidance, organizational change management services, and experienced project execution resources to help the client implement their network strategy.

  • Defined organization structure, processes and responsibilities: Provided change management leadership to define future state processes, with a heavy focus on interdepartmental process integration. Created a communication plan to help manage the organization and stakeholders through the change.  
  • Implemented technology: Helped design and implement multiple solution components, including: a custom SAS solution for analytical algorithms, a custom application to manage workflow and security for key operational processes, a third party vendor solution to deliver provider facing reporting, and enhancements to existing applications to enable provider payment and self-insured employer group funding.
  • Enabled compliance with national organizational mandate: Helped translate high-level mandate requirements into technical specifications and processes.
  • Program and project management: Provided project management leadership around more agile approaches to project execution, decomposition of scope, creation of project plans, and execution tracking. Created design documentation, created and executed test plans, constructed specific system components, tracked defects, and supported release management.

Business results

Client successfully adopted new processes and systems to allow them to administer and grow their ACO model.

  • Scaled programs: Grew the number of participating provider partners in their programs from three ACOs at program launch to fifteen ACOs over a single year.
  • Improved internal stakeholder integration: Business process owners from five primary departments now collaboratively manage the on-going operations necessary to run the program.
  • Improved processes: Business processes are executed on an ongoing basis to define ACO populations, deliver data to health system partners, and manage payment and funding transactions. Hundreds of analytical programs are executed each month, delivering multiple data sets to each provider partner. Automated financial transactions support execution of tens of thousands of transactions per month.
  • Improved technologies: Significant demand from other network providers to participate in our client’s value-based care programs continues. They are now positioned to achieve the desired scale of the program via improved technologies and automation of business processes.

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