Let Presscott Associates serve as your agent of change and develop a meaningful balance of interests for all of your relevant stakeholders!

MEDICAL EXPENSE MANAGEMENT

We add the value of economics to the assurance of healthcare.

Most health plans are currently faced with the challenge of operating efficiently in an environment of tightly-managed cost structures, variability in provider contract terms and a need for continual cost-benefit assessments (see Economic Value Analysis) of medical management programs. Ultimately, health plans that are proactive in developing and maintaining aggressive and realistic cost containment programs will sustain a more competitive position in the marketplace (e.g., premium and benefit plan structures).

With our approach to Strategic Relationship Management, your organization can benefit from the management consulting services offered by Presscott Associates. We will confidently implement a formal business relationship and plan with your providers and vendors that will promote “win-win” results. We meet with our clients to understand the business, culture, goals and context of the health plan’s expressed needs, and from this understanding, design customized services to address the objectives of the engagement. Some examples of Presscott Associates’ management consulting services include the following:

Managing units of service
– Analysis of specific in/out-of-network cost trends and identification of the drivers of cost; recommendation of
strategies to manage both in/out-of-network costs
– Trend analysis for the ER, lab, outpatient surgery, radiology, oncology, professional services, ancillary services and
disease management initiatives
– Medical management assessments, with a focus on coordination of care and the cost/benefit of such programs
– Assessment of the effectiveness of current pre-authorization programs and recommended modifications
– Development of quality incentive programs (e.g., Pay-for-Performance)

Managing unit cost
– Assess provider contract structures and recommend changes in accordance with local and national marketplace
   trends including:
    •• Conversion of per diems to case rates to increase cost predictability and potentially minimize certain aspects of
         medical management intervention
    •• Conversion of outpatient fee schedules to APCs for commercial lines of business (LOB)
    •• Assessment of the financial implications of Medicare initiatives on health plans and their hospital networks
         (e.g., Present on Admission regulations, Hospital Acquired Conditions, and new DRG groupers)
– Assess provider trends regarding new technology and procedures
– Audit provider-specific implant spend; develop implant fee schedules; feasibility of pre-authorization for implants
– Analysis and management of in/out-of-network expenses (e.g., standardization of business rules for
   technical/professional services and allied health professionals and establishment of out-of-network fee schedules)
– Management of injectable spend incurred as a medical benefit
– Cost management of the Medicare and Medicaid populations, including disabled/SSI beneficiaries

Policy enforcement and claims payment accuracy
– Medical policy compliance reviews pertaining to claims adjudication
– Standardization of claims adjudication business rules (e.g., out-of-network services)
– Contract compliance reviews (e.g., provider chargemaster increases and new technology carve-out compliance)
– Audit external/internal Pharmacy Benefits Manager (PBM) programs on a retrospective/prospective basis for
commercial LOB and Medicare Part D

Let Presscott Associates serve as your agent of change and develop a meaningful balance of interests for all of your relevant stakeholders!