Managed Care Advisory Services

Charge description master analytics

Federal pricing transparency regulations are intended to help prevent unexpected medical expenses by providing consumers with the estimated cost of services before they receive care. Although this helps increase competition among providers, there are challenges to understanding and complying with pricing transparency while also incorporating it into existing managed care arrangements. Baker Tilly can help evaluate current methodologies and pricing, as well as validate billing codes, to reassure charge structures and pricing are aligned with local marketplaces to better prepare organizations to smoothly transition to pricing transparency.

Managed care benchmarking

Understanding where a provider’s performance compares in the marketplace can help healthcare organizations develop proactive contracting arrangements that can advance your payer relationships well beyond the traditional fee-for-service (FFS) platforms. Baker Tilly is able to use empirical claims data, as well as emerging market intelligence, to develop next-level payment models that align provider prices with marketplace competitors in order to help providers retain business, optimize reimbursement and yield sustainable financial returns.

With the help of our experienced professionals and our licensed IBM® MarketScan® Research Databases – one of the largest proprietary U.S. claims databases – we are able to provide organizations with the information that will help provider organizations benchmark against their competitors. Whether you want to know about your geography’s disease prevalence, average payments for procedures, utilization patterns, or other specific insights, Baker Tilly and IBM® MarketScan® are able to offer your organization the most up-to-date data so that you can make more informed and confident decisions.

Performance and risk-based assessment and contracting

Understanding where an organization is positioned in the market and what risks are the best fit are paramount to succeeding when implementing value-based care (VBC) arrangements. Proactive planning and understanding the dynamics of risk when transitioning as a new entrant, or when moving to the next level of VBC, are key to mastering the Triple Aim approach of improving patient experience, improving health outcomes, and reducing the per capita cost of healthcare.

Baker Tilly can help organizations prepare and enhance the performance and risk-based arrangements of providers by identifying gaps and opportunities with our value-based readiness assessment program. Using our proprietary assessment tool, our team of professionals are able to assess provider organizations’ level of readiness to implement VBC contracts while also identifying key transformation activities required to realign and optimize risk-based strategies, processes and enabling tools. Our framework consists of four unique phases, which can be leveraged individually, in any combination, or all together based on an organization’s level of VBC program maturity:

• Feasibility: Determining a provider’s readiness to implement a VBC arrangement by assessing the current state of the organization’s operational and technical capabilities, as well as its external stakeholders and marketplace factors.
• Design: Establishing a VBC program that can be agreed upon by the provider and health plan partners, and that incorporates detailed business rules and capabilities that are required to operationalize the program.
• Enablement: Implementing and helping the people, processes, and technology required to build the new, or expanding an existing, VBC program that is operational and efficient. 
• Monitor: Ensuring providers have the necessary tools to track the success and optimize the performance of their existing VBC programs.

Bundled and fee-for-episodes payment design and modeling

Based on case rate payment methodology experience, healthcare organizations can often find that one of the easiest transitions to VBC is through bundled and fee-for-episode payments. Baker Tilly can evaluate the readiness of healthcare organizations and identify which payment models are the right fit. Our Bundle and Episodic Payment (BEP) tool, in collaboration with our revenue cycle management (RCM) and optimization services, can help determine which procedures, healthcare organizations and reimbursement structures are a good fit, as well as identify the projected financial risks that are associated with the bundled or episodic service.

Service line analysis

As inpatient hospital surgeries continue to migrate to the outpatient patient setting, ambulatory surgery centers and minor surgical procedures provided in private physician office surgical suites are expected to grow at 5.6% annually and reach an estimated value of $84.1 million by 2027. Healthcare providers will be required to keep up with trending market demands, adjust their prices and manage where and how they provide services to consumers. Baker Tilly can assist providers seeking to retain and/or increase patient revenues and remain competitive with strategic benchmarking market analysis that can help businesses anticipate and understand the shifts of healthcare services within local marketplaces.

Managed care predictive modeling

Healthcare providers have the greatest chance of becoming, or remaining, financially sustainable when they are acting proactively, rather than reactively, to the evolving healthcare marketplace. Understanding the return on investment and identifying economic vulnerabilities are also crucial when making future financial decisions. Baker Tilly can help organizations develop short-term and long-term strategies with the use of predictive analytics by analyzing and modeling potential marketplace scenarios, which can help drive predictable financial results – through profitability or by mitigating loss – to better understand the financial implications of the marketplace and so they can better prepare for the future.

Fee-for-service continues to play a primary role in managed care contracting and is projected to remain a viable payment structure option for healthcare organizations. Understanding the impact of market trends, having advanced analytics capabilities, engaging with stakeholders and executing a well thought out strategy are all crucial to successful contract negotiations. Baker Tilly is able to assist in navigating the challenges of rate negotiations, payment rules and methodologies, revenue forecasting and contract language development that affects revenue. Our team provides the experience required to effectively evaluate and manage healthcare organizations' managed care agreements to improve their profitability.

Providers must actively oversee their managed care contracts, relationships and payments while also remaining focused on other pressing issues and commitments. Baker Tilly can provide a range of outsourced interim managed care management solutions, including:

• Long-term and short-term staffing support
• Calculating model reimbursement rates
• Organizing department functions and structures
• Developing contract management databases
• Tracking contract performance and corresponding revenue

Enhanced revenue strategies (VBC optimization)

Many health systems accept that their key physician group(s) will lose money, but they do so under the assumption that these groups will generate profitable referral volumes to the larger health system. At Baker Tilly, we do not accept that these physician groups will lose money; we believe they can generate some margin if you combine the expense reduction strategies noted below with a thoughtful VBC contracting strategy that can deliver meaningful incremental revenue.

Expense reduction strategies

Providers are considering alternative possibilities to reduce expenses and streamline healthcare costs for patients and employers. Reviewing physician staffing, performance and compensation models can reduce healthcare prices, and improve quality and patient experiences required to meet the demand of empowered consumerism. Baker Tilly can help with conducting a full cost-benefit analysis and performance review to recommend the most preferred staffing models to reduce excessive costs and expenses associated with the delivering healthcare.

Integration strategies

Attracting payers and securing VBC contracts requires providers to demonstrate they have an engaged physician organization to deliver on their commitments. To succeed in a VBC environment, providers must establish and demonstrate their medical professionals are integrated and invested in the leadership of the organization, and are high-performing providers that deliver quality care with optimal outcomes. Baker Tilly can advise which type of physician organization model will produce the most desirable results. We have worked with clients to help create and design the following physician alignment models:

• Clinically Integrated Networks (CIN)
• Integrated Delivery Networks (IDN)
• Physician-Hospital Organizations (PHO)
• Patient-Centered Medical Homes (PCMH)
• Independent Physician Organizations (IPA)
• Partially Integrated Medical Groups (PIMG)
• Fully Integrated Medical Groups (FIMG)
• Management Service Organizations (MSO)

In addition, our experts assist with developing strategies and roadmaps to help providers become more organized on their path towards success in value-based contracting.

Managed care due diligence

Private equity and venture capital investment in the healthcare industry continues to increase at an exponential rate. With the financial effects of COVID-19 acting as a catalyst, many businesses are increasingly considering the decision of combining with, or selling, their practice to avoid insolvency. Baker Tilly understands both the private equity and healthcare industries and has the experience needed to advise organizations on their financial viability and healthcare investments. Our team has a comprehensive set of services to help organizations who are considering M&A strategies through our due diligence, valuation and tax planning solutions.

Healthcare feasibility study

For organizations looking to add to their growing provider portfolios, healthcare organizations want to be certain about which approach will be best, whether it is through expansion, joint venture, acquisition or new development. Furthermore, opportunities to provide new healthcare services, capture additional market share and increase patient revenue exist when an idea is turned into a viable plan. Baker Tilly can assist clients with a wide range of solutions to help leaders make more informed decisions and develop comprehensive business plans, including market analyses, business projections and financial forecasts.