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Managed Care
Related Services

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  1. Managed Care Dashboard and Performance Report Development

  • Determination of types of executive dashboards required and/or recommended

    • Membership and Enrollment

    • Member/Patient Demographics

    • Access to Care and Capacity

    • Inpatient Utilization

    • Outpatient and Ancillary Utilization

    • Financial (Profitability)

    • Patient Experience

  • Key performance measures and drilldowns

  • Assessment of available data sources and systems

  • Decision on new data to be collected

  • Mapping of data sources and fields

  • Construction of dashboards

 

   2. Eligibility and Capitation Reconciliation

  • Outline process for the routine and monthly reconciliation of eligibility and capitation files from health plans

  • Develop procedures for incentive and risk pool reconciliation 

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   3. Capitation and Fee-for-Service Rate Review

  • Review of approach, development and assumptions including, but not limited to, examination of capitation rate tables, assessment of process and considerations and project plan for construction of rates, pools, carve-outs, and incentives, as applicable.

  • Recommendations on proposed rates and/or rate ranges including adequacy (applicable base data adjustments, managed care adjustments, claims cost trends, and risk adjustments for current and subsequent periods covered) and/or soundness (capitation rates and other revenue sources provide for all reasonable, appropriate and attainable costs).

  • Review of rates paid for provided and/or purchased medical services.

 

   4. Meetings and Conferences

  • Participate in planning committee meetings and/or project planning sessions. 

  • Meet with administrative, clinical and/or operational staff.

  • Meet with executive project owner and/or project manager on regular basis.

 

   5. Written Reports and Recommendations

  • Provide periodic status reports to executive project owner/sponsor.

  • Prepare and present written recommendations on managed care infrastructure.

 

   6. Knowledge Exchange

  • Provide information and expertise on managed care infrastructure to key stakeholders.

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