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Annual Georgia Managed Care State of the State Webinar

Annual Georgia Managed Care State of the State Webinar

Join us on December 22nd @ 12p Eastern as we present our Annual Georgia Managed Care State of the State.  We have a lot to cover, including:

  • Key elements of current and anticipated market themes from commercial carriers
  • Where the Medicaid Managed Care and Medicare Advantage markets stands today
  • Value Based Care models and what we are anticipating for 2022
  • Ideas to help you address your managed care strategy

Join us at 12:00 noon on Wednesday, December 22nd via this link (no registration required).

We look forward to seeing you!

SHP Lunch ‘n’ Learn – Tomorrow, Sept 16th @ 12pm

As a reminder, the SHP Fall Lunch ‘n’ Learn series are continuing on with sessions scheduled over the next two weeks.

Please join us at 12:00 p.m. tomorrow, September 16, 2021, for an update on Georgia’s Managed Care market and developments; from what’s coming in 2021 from Medicare Advantage expansions to new Healthcare Exchange offerings to the conclusion of the PSHP/WellCare merger.  As the market continues to shift and narrow based on payer mergers; we’ll also talk longer-term strategy considerations to encourage competition in the market.

For the best experience, please join us using the link below:

And next week, September 22, 2020, we are thrilled to be joined by Department of Community Health Commissioner Frank Berry and Deputy Commissioner Blake Fulenwider. To join us for the physician session that will begin at 12:45 p.m. and will run approximately 45 minutes.

2021 is shaping up to be a big year for DCH, and we encourage you to join and hear from Commissioner Berry and Deputy Commissioner Fulenwider updates including the following topics:

  1. PSHP will officially take over WellCare’s Medicaid population in May 2021.
  2. DCH will re-procure the carriers for State Health Benefit Plan… is crucial in light of BCBSGA’s recent actions regarding physician contracts that DCH hears from physicians around the State how critical it will be to have additional options outside of BCBSGA & UHC.
  3. DCH will continue to pursue their Medicaid/Exchange plan waivers to expand Medicaid coverage in the State.

For the best experience, please join via the link below:

We look forward to talking with you then!

Supreme Court Sides With Hospitals in Multi-Billion-Dollar DSH Formula Dispute


Today, the Supreme Court released their decision regarding a hospital lawsuit against the Department of Health and Human Services (DHHS).  Several hospitals had joined together to sue DHHS regarding a previous rule change in the calculation of disproportionate share hospital (DSH) payments which began in 2014. The DSH payment change had reduced payments significantly to PPS hospitals. The Supreme Court has ruled in favor of the hospitals that this change violated the Medicare Act since it was not subject to public comment and the established rule-making process for government agencies.

The estimated impact of this decision is estimated in an additional $4 billion in DSH payments owed to hospitals for payments made since the 2014 rule change.  Additional details can be found here.

At present, DHHS has not commented on the ruling. SHP will continue monitoring the developments on how DHHS will be reissuing corrected payments based on the Supreme Court ruling and will keep you posted.

Primary Care First: Why CMS’ Latest Program Truly Matters

The Centers for Medicaid and Medicare Services (CMS) released yet another voluntary payment model intended on restructuring financial reimbursement for primary care services. At face value, Primary Care First furthers many of the underlying concepts utilized in CPC+ by generally offering upfront Per-Member-Per-Month (PMPM) payments to providers while theoretically undercutting the financial pressure for primary care physicians to push volume of appointments over meaningful time spent with patients. Primary Care First intends to upend market realities that straightforward Fee-For-Service reimbursement pressures put on providers to drive focus towards patient outcomes.

Just another CMS pilot? Maybe. It’s worth looking into this long stream of programs and initiatives CMS has unveiled aimed at re-prioritizing primary care, to clear up time for patients with complex chronic ailments. This simultaneous effort to increase patient health outcomes and reduce total costs of care may seem like just another theoretic framework doomed, waiting to face harsh practical realities to an untrained eye.  Though this multiprong effort intending to liberate a primary care office from the many inefficient entanglements’ providers face, simply trying to get paid for providing care, there is a more impactful lesson here. So, what makes Primary Care First different than any other lofty so-called “Re-design”? Nothing.

Nothing except for a potentially brand new medical framework to prove your ability to offer effective care coordination that actually reduces readmissions, unnecessary ED utilization, and simply shows your personalized care plans works better for your patients than your competitor down the street. Nothing except for the capability to pivot PMPM success from CMS to your local employer and payors, with data, infrastructure, and legal means to do so. Nothing except for a temporary breath of financial fresh air to contemplate your own practices to see how you can meet patients on their terms, rather than in the terms of a Medicare Fee Schedule. Nothing except another source of profitable information your Clinical Integration Network can bring to the negotiating table. How so?

In order to change our current circumstances, we need to change the conversation. So, how can we change the conversation? Easy, develop something new to talk about, that is worth talking about, and then talk about it, a lot.

Something new to conversate with your local self-insured employer groups may be your recent successes in reducing avoidable admissions amongst your highest acuity patients. Something new to conversate with a large local employer may be your home-grown lower-back pain “clinic” that you integrated into your practice that created a pathway toward therapeutic rather than surgical care, when appropriate.

See a trend here?

Something new to conversate with your regional Medicare Advantage payors may be your successful annual wellness visit in which an NP captures over 80% of your patients on a yearly basis, funneling them to their PCP when necessary with a practical team-based care model. They’d certainly be interested in hearing how you developed a pathway to document HCC coding for 80% of your eligible patients. The thinking is simple, do not undervalue how swiftly you can position recent action into conversation, and bring that conversation to those that need it most. With a bit of disciplined strategic discussion and transparent action, primary care practices are perfectly positioned to dovetail any population health success in quality, clinical outcomes, and financial savings with CMS to interested parties down the street. Those who struggle to see this, will likely continue to face new disrupting competitors showing up unannounced with proven evidence at succeeding in reducing non-value adding health costs by providing technologically-advanced personalized team-based care that patients, employers, and providers all desire.

Need help with your contracting strategy? Click here to learn more about our services.

Medicaid and CHIP Managed Care Network Adequacy

In mid-November 2018, the CMS, under the direction of the Trump administration, proposed highly anticipated modifications to managed care regulations that were put in place back in 2016. These modifications would grant states more flexibility in determining network adequacy standards for Medicaid managed-care plans, with intentions of aligning Medicaid regulations more closely with Medicare Advantage standards. Simply stated, the intent was to generally increase the privatization of Medicaid Managed Care and limit federal financial involvement.

Given that Medicaid Managed Care Organizations behave similarly to self-insured employer groups, states vary in the levels of financial risk taken when contracting with participating provider networks. This relationship creates a unique opportunity for provider networks to either solidify their network by aligning with other existent contracts, or more realistically, a chaotic scenario involving a misaligned blend of Medicaid, Medicare Advantage, and commercial participation within a provider network, or even individual physician office. This brings the all-too-familiar patient confusion, revenue cycle difficulties, front-office misunderstandings, and overall provider enrollment nightmares.

Of the many aspects of the proposed rule, that will soon be publicized as a final rule, include:

  • Pass-Through Payments – This proposal expands states’ authority to direct payments from plans to providers in states transitioning towards Medicaid managed care from traditional Fee-For-Service models. The proposal is a three-year period that permits states to require payments that equate Fee-For-Service reimbursements to ease the financial transition for provider organizations and healthcare facilities.
  • Testing Value-based payment reform – This proposal permits increased authority at the state level to offer value-based payment models potentially reflecting value-based methodologies used in Medicare Advantage and commercial markets. It is noteworthy that this does not directly mimic Medicare Advantage frameworks which reduces much-needed value-based synchrony but offers regional flexibility for provider groups to actively negotiate mirroring value-based contracts with a traditionally siloed payor class such as a CMO plan.
  • Provider Network Adequacy – Currently, states enforce network adequacy standards that include time and distance standards for various provider specialties. Many argue this deters telehealth and telemedicine capabilities that could allow networks to include distant professionals. This proposal eliminates this requirement completely and replaces it with quantitative network adequacy standards that may include loosely defined provider-to-patient network ratios. Completely removing the time and distance rules for even primary care providers caused significant concern with provider organizations, which is likely to be addressed in the final rule. Additionally, states would now maintain the authority to define “specialists” in terms of network adequacy standards.
  • Rate Ranges – The proposed rule allows rate to vary only by beneficiary or service characteristics, unlike the current reliance on the level of Federal Financial Participation (FFP). Importantly, this rule modifies the stipulation that payment modifications must be delivered based on sound actuarial principles. This means any revisions and underpaid reimbursement due to a variety of rate-related issues could be simply denied.
  • Coordination of Benefits (COB) – As managed care enrollees are often covered by multiple sources (Dual eligibility in Medicare Advantage, specialized behavior/dental care, etc). Currently, the proposal offers states the flexibility to route claims as they chose rather than the existent policy that leverages Medicare’s claims routing methodology.

Further Information provided by The Centers for Medicare and Medicaid Services can be found here.

Tips for Creating Engaging Content


In the age where Buzzfeed listicles dominate and memes have replaced words, it’s difficult to figure out how to create blog content that will keep a reader engaged past the title. The good news? We have some tips on how to hook those readers in and keep them coming back for more.

1. The acronyms are actually important.
The digital age is filled with talk of the almighty SEO, or Search Engine Optimization. The lofty air surrounding SEO engagement is actually pretty vital to a blog or really any digital marketing campaign. Keywords lie at the heart of SEO optimization. They’re the main points of your content and will help Google guide potential readers to your site. This is not to say that you need to throw a million keywords in your blog so that the actual points are muddled with Google-nonsense. The reason why someone clicked on your post was because they were interested in the title and/or topic, so make sure you deliver on that promise.

2. Images, Images, Images
Unfortunately, most people won’t stick through text-heavy content. To get people to keep reading, come up with creative subtexts, organize the information into bullet points or lists, provide links to other sources, and include those images and/or videos. In this article by The Guardian, research shows that videos are the way of the future, so partner with YouTube and start cranking out interesting clips to accompany your blog posts.

3. Give your readers something in return.
Sure, the information that you’ll be providing is a gift enough, but sometimes creating even more engaging content means providing the readers with something tangible. Perhaps for a share, your reader can download some cool treat (i.e. white paper, ebook, video) that relates to the blog content? Creating contests will also help boost your fan base. People love to compete, and what better way to get your business out in the virtual sphere than by having people share your information for a prize?

4. Grammar is actually important!
Play with words to make your copy more lively and fun to read. Know when to be direct and when it’s proper to be passive. Depending on your company, some topics should be said in a more approachable manner with suggestions rather than rules. As we’ve been doing, use the second person to talk directly to the reader. Yes…you! Keep your tone of voice in mind when creating content as well. Nothing will put a reader off more than an unfriendly or rude tone.

5. Literally engage your readers.
Listen to what your audience is saying about a particular product/trend/whatever your business does, then try to get them to respond on your blog. Ask questions. Be inviting. Encourage comments.

6. And your point is?
Throwing out lots of jokes and using fancy jargon may be great for some circles, but when it comes to getting people to engage with your content, stick with what appeals to a broader population. If your witty title talks about how to create engaging content, for instance, than what follows that heading should be all about that topic. (Are we doing okay?) It’s also a good idea to follow current trends. Entrepreneur says it best, “Specific triggers get more people to share our content, spreading our message, gaining traction, winning customers and beating the competition.”

Written by Jeremy Miller with Boost by Design.

The Life Cycle of a Resume


When recruiting for a job, companies look for many things before they even pick up the phone to call you for an interview.  Most people think that when you, the potential job candidate, submit a resume online, it gets screened by either a computer program or human, and then you are either called or the resume is put in the rejected pile. However, there is much more to the recruitment process than you think.

Let’s start at the very beginning. The candidate finds your job posting. Something about what you have written interests them. They think… “This is perfect for me” or “I can do that.” They then put together their resume, write a cover letter, and hit the send button.

I am sure most candidates assume that the recruiter begins reading their cover letter before they even look at a resume. That really is not the case; in fact, it is more likely than not the cover letter will never even be read. Oh yes, as recruiters we highly encourage the candidate to write a cover letter, but in all honesty, on average per job opening we receive about 250 resumes with a cover letter attached. Odds are we are not going read the cover letter; we are going to go straight to the resume. Only about 23% of the cover letters sent are read. We ask that you submit cover letters because if it comes down to you and another candidate, we will look at the cover letter and check to see who would be a better fit.

Next, either the computer app recruiter’s use, scans for key words in a resume and then flags it as something you must see or you personally go through each resume. It takes an average 5-7 seconds for a resume to be scanned, either by a human or a computer. That is right, I said seconds. It takes longer for you to make a sandwich. Although it only takes a few seconds to scan the resume, it only takes about 1 second to notice a grammatical error or typo in a resume. It is like a spotlight is shown on this one tiny mistake, and it then blinks at you over and over again.

I understand, when you are young and creating an email address, you think… “I will be creative with it, it is going to be”  Now, that is great when you are 11 years old; however when you in your 30’s sending out resumes, it is not so professional and the recruiter will not take you seriously. So there goes the resume….in the rejected pile.

Last, but not least, social media is here to stay. As recruiters we are going to see if you have an online presence. We want to see if you are someone we want representing our company by what you post. If you just post about your family and pets, then odds are we are going to pick up the phone and call you for an interview. If you post how much you hate your job and co-workers, we will probably send your resume to the rejected pile. 1 out of 4 recruiters will reject you based on your online presence.

Before you hit the send button on your phone, computer, or tablet, think to yourself…Is my resume grammatically correct/no typos; Does my cover letter sell me and what I have done and what I will do for the company; Should I change my email address that I have had since I was 11 yrs. old; Are my social media accounts set to private and how do I look if an employer should look at my profile? But above all, remember you are a professional; therefore, your first impression should be as a professional.

Written by Karyn Koch.

Gossiping vs Venting in the Workplace


Everyone has a friend/colleague that we like to discuss things with such as work or other colleagues in the workplace.  We like to discuss the good, bad, and ugly of our workplace stresses, frustrations, and annoyances with our friend/colleague…does this mean we are gossiping or is it just venting? This is a grey area for most, so hopefully this will give you some guidance of when venting can become gossip.

Venting is commonplace in the workplace; in fact it is inevitable. At times we need that friend/colleague with whom we can share our frustrations with and that is absolutely ok.  In fact, many would say venting can be a healthy release of stress and frustration for some. When we vent or a colleague vents their annoyances or stressors constantly, please keep in mind this can spread negativity and be disruptive to your co-workers just as much as gossip. But like all things, we should always think before we speak.

One of the most important things to think about when venting is to choose someone who can be objective about whatever you are saying. The second thing would be to tell someone who is going to keep it confidential. Most of us process our feelings by talking them out with someone or we need help figuring out how to respond. Venting is totally appropriate during these times.  A good friend/colleague should be someone you can rely on to be honest with you good or bad.

It is very easy for us to get in the habit of venting about every little perceived grievance in the workplace. Be mindful that this can create a workplace reputation for you as a complainer. You can minimize the impact you are having on your fellow teammates by not venting any frustrations at work itself but go to lunch with your friend/colleague or discuss it after hours. Venting is not something you would want to do in an open space, say near the copy machine, because someone will overhear you and can misconstrue what you have said and then turn that into gossip.

Now here is the grey area when workplace venting can be perceived as workplace gossip. You should start by asking yourself some simple questions: is the information you are sharing yours to share, why would this person need to know this information, and is it true? Keep in mind, even if something is public domain, it doesn’t always make it right to repeat it.  The second question is slightly harder for us to qualify. If you are sharing information about someone as a warning to not repeat their mistake or to help see things clearer, then it is not gossip. However, if this information is being shared for no other reason than to share information that is hurtful or not flattering, then not only is it a bad habit to share; it is gossip. Even if you are stating a fact, that doesn’t mean it isn’t gossip.

Whether you are gossiping or venting about work, please balance the negative with the positive and come up solutions. If you or your colleague only focus on the negative things about work, you are never going to be happy with yourself or your job. Start coming up with solutions to things you feel are impacting the company negatively and voice your solutions so you can be a part of the change and not the problem.

If you are tempted to vent or gossip, please think before you speak. Think what the repercussions could be as to what you are saying. We are human, and we will continue to fall in the grey area. Hopefully, these steps and questions you will ask yourself will help you to stay in the venting category as opposed to the gossip category.

Written by Karyn Koch.

Medicare Advantage: In-Network vs. Out-of-Network

Medicare Advantage plans continue their unabated growth; in 2019, plan options across the United States have grown by 20% from 3,100 plans in 2018 to 3,700 plans in 2019.  By 2025, it is expected that Medicare Advantage market saturation will reach 50% of the Medicare-eligible population.

With unprecedented growth in these plans also comes increasing administrative challenges and roadblocks.  These range from never-ending record requests to non-Medicare claims payment methodology to lack of operational oversight on these issues.

As stewards of their communities; most healthcare facilities automatically participate in the health plans being sold in their markets.  In light of the increasingly challenging administrative burdens, it’s critical for healthcare facilities to seriously consider “Why Should I Contract for Medicare Advantage?”  In making a determination for in vs out of network participation; some of the key points worth considering are:

  • Type of Medicare Advantage Products in Your Market: what is the product saturation in your market?
    • PPO: In & Out of Network Benefits
    • HMO: No Out of Network Benefits
    • PFFS: No Network Offered; Benefit Level Identical at Any Service Location
  • Plan Design: can enrollees see you out of network with no negative financial impact?
  • Network Reimbursement:
    • Out-of-network services reimburse at Medicare rates using underlying Medicare methodology
    • In-network services reimburse at contracted rate using methodology developed by the health plan; some key differences noted in plan design:
      • Extensive recoupments
      • Non-Medicare methodology:
        • What are covered services?
        • Length of stay limitations
        • Sub-Medicare rate methodology
        • No alignment with CMS rate methodology; i.e. paying home health under per diem reimbursement methodology
  • Record Requests: Under CMS’s methodology for paying Medicare Advantage plans, health plans are laser focused on risk adjustment leading to a never-ending stream of onerous record requests. In an out-of-network position; there is no requirement to comply with these record requests.

It’s critical for managed care departments to weigh the benefits of being in-network with a Medicare Advantage plan and if that benefit outweighs the administrative burden.

Learn more about our managed care contracting services and how we can help.

Continuity of Care QPP Measures

Introducing continuity of care measures to the Quality Payment Program (QPP) may be the best route to lower healthcare costs and reduce hospitalizations according to a study recently published in the Annals of Family Medicine. Provider-level measures that support value-based payments by measuring true continuity of care have been lacking thus far in QPP. This led Dr. Andrew Bazemore to develop, and test 4 provider-level, claims-based continuity measures on over 1.4 million Medicare beneficiaries.  The results showed providers with the highest level of continuity were 14.1% lower in cost than those in the lowest quintile. In addition to the cost savings, the odds of merely being hospitalized decreases 16.1% for providers with a high continuity of care score.

Researchers utilized four established measures, the Usual Provider Continuity (UPC) Index, Bice-Boxerman Continuity of Care, Modified Modified Continuity Index (MMCI), and the Herfindahl Index (HI) to then create an average across provider-level patient panels. The strong correlation between these continuity of care measurements and both clinical and fiscal outcomes, builds a strong case for supporting further focus on care continuity with providers and clinical teams. This may not be all that surprising to primary care providers, as a stronger patient relationship is often given credit for better care. However, this is a big win in terms of bridging the gap between a world of healthcare dominated by data and the real world of complex dynamics between patients, providers, and individual life circumstances.

The applicability and ease-of-reporting for these four measures is astounding in comparison to the barrage of primary-care centric measures currently in QPP. Researchers noted, “Primary care has the largest number of QPP measures but most of these are intermediate, disease-focused, and process measures, which risk driving primary care focus away from its core functions and real value.”

As value-based payments continue to snowball into effect, support for reasonable, applicable measures that bring minimal reporting burden is encouraged. To learn more, please see the Meaningful Measures Initiative here.