This article is second in our series examining the long-term impact of COVID-19 on health and healthcare issues for the self-insured industry.
Chronic conditions are the leading cause of death in the United States, as well as the primary driver of our $3.5 trillion annual healthcare costs. Long before COVID-19 hit, providers, payers and self-insured employers grappled with the challenge of ensuring that patients with chronic illnesses receive effective care.
Recent surveys indicate many patients have put their chronic care needs on hold during the pandemic, potentially leading to more expensive scenarios in the future. Consider these findings from a recent survey:
- Seven in 10 patients reported a negative impact on their ability to manage their high-risk conditions due to COVID-19, with one in four expressing a high impact.
- One in three patients reported a reluctance to leave their homes for treatments, with 70 percent sharing they were more worried than usual about their health at this time.
- Less than 40 percent of respondents felt prepared to manage their health during COVID-19, with more than half expressing concern they would lose access to essential care.
- More than one in 10 patients reported they were unable to receive their medication.
Even with heightened safety precautions that have made office visits and routine care widely available again, many patients have been slow to return – especially for people with long-term conditions like asthma, heart disease and diabetes, who are at significantly higher risk of severe illness from COVID-19.
As the health industry adapts to consumerism by adapting care deliver to meet the evolving needs of consumers, so too must payers and self-insured employers. Here are five solutions that take significant steps towards improving service and care for chronic disease patients during the pandemic and potentially beyond:
1: Telehealth and virtual care
Expanded telehealth access has been the key component of the rise of virtual care utilization, allowing care continuity while all parties maintain physical distancing. Combined efforts by the federal government, individual states, private insurance companies and self-funded groups have facilitated telehealth as a viable care option during the pandemic, lowering regulatory barriers that had limited its use and the reimbursement of services. According to the American Medical Association, physician telehealth adoption is now estimated at 60-90 percent.
In addition, a survey by Accenture in July 2020 reported that providers were largely able to maintain or even improve on the patient experience with virtual care technology, which also includes live video, audio and instant messaging. With 41 percent of respondents taking advantage of virtual tools – the majority of them for the first time ever – patients reported more personal interactions, faster response times, and the convenience of managing care from home. Virtual care and telehealth are proving especially useful for chronic disease patients in rural and remote areas.
2: Patient-centric care navigation
For self-insured employers, brokers and third-party administrators, care-coordination solutions like NaVcare help members navigate their health journey more effectively, delivering personalized service and guidance for high-quality care and improved outcomes. Real-time data-driven insights, combined with in-depth health plan knowledge, are critical for identifying patients with complex, chronic conditions. Providing those patients with comprehensive care management helps avoid more serious and costly health events.
Informed by data – including claim, pharmaceutical and demographic data –NaVcare tailors services to each employer and illuminates individual care needs for members. Care navigators facilitate virtual care when available for enhanced patient convenience and engagement as well.
3: Behavioral health integration
People with chronic diseases are more likely to experience depression or behavioral issues as they often face impaired mobility and loss of independence. According to the Center for Medicare Advocacy, 43.8 million U.S. adults struggle with mental illness each year, and 26 percent of those are Medicare beneficiaries – a population that is highly vulnerable to the effects of isolation, increased stress and more limited access to regular care, even before the pandemic.
Traditionally, the care delivery models to address physical and behavioral health have been independent of each other. More and more, providers and health organizations are acknowledging the significant correlations between physical and mental health, turning to integrated care solutions that treat the whole person and deliver improved outcomes with lower costs – up to 10 percent savings in the nation’s overall healthcare expenses, according to the American Psychiatric Association.
4: Prescription cost management
Following a national trend that has continued for the past decade, costs have risen for chronic disease medications and depression/anxiety drugs during the pandemic, with total prescription spend predicted to reach $610 billion in 2021. Before COVID-19, one in three Americans did not take their medications as prescribed because of high costs, but during a global pandemic, forgoing medications involves even more risks for chronic care patients and incurs even higher costs in the long run.
Cost-containment solutions for self-insured employers, brokers and third-party administrators include a range of PBM solutions and specialty medication case management services. Such solutions create long-term reductions in medication spend while passing on lower costs to members and delivering highly personalized case management services and advocacy.
5: Remote patient monitoring
Recent studies connecting COVID-19 to long-term heart and lung damage, among other serious conditions, accentuate the benefits of remote monitoring technologies for high-risk patients. As it tracks and transmits vital signs in real time, remote patient monitoring allows providers to regularly check pulmonary function, blood pressure, body temperature and other physiology for proactive management of changes in disease progression.
A joint report from AHIP, the national association of America’s Health Insurance Plans, and C-TAC, the Coalition to Transform Advanced Care, concludes that remote patient monitoring is among the most efficient and effective tools available to manage chronic disease — particularly in older patients with diabetes, heart failure, and chronic obstructive pulmonary disease.
Solutions for today and tomorrow
Patients with chronic illnesses are more vulnerable to some of COVID-19’s most significant threats. As the global health crisis continues to present new challenges in treating patients with long-term conditions, it also has opened up new opportunities. It is exciting to be part of the evolution of solutions that will serve patients well beyond the pandemic – showing us all the next level of smarter, better, faster healthcare.
***
Rob Gelb is Chief Executive Officer of Vālenz™, one of the nation’s leading data-driven, medical cost containment and care management organizations offering expanded solutions to support the self-insured industry.
About Valenz
Through a complete health administrative ecosystem, Valenz connects cost and quality data on a single-source, end-to-end analytics platform for smarter, better, faster healthcare. Valenz solutions integrate data from comprehensive care management services (Valenz Care), high-value provider networks (Valenz Access), claim flow management (Valenz Claim) and solutions for payment integrity, revenue cycle management and eligibility compliance (Valenz Assurance) into the ecosystem. More information is available at valenzhealth.com. Valenz is backed by Great Point Partners.
About Great Point Partners
Great Point Partners (“GPP”), founded in 2003 and based in Greenwich, CT, is a leading healthcare investment firm, currently with approximately $1.8 billion of equity capital under management and 28 professionals, investing in the United States, Canada and Western Europe. Learn more at www.gppfunds.com.
Maurice Steenland Joins Vālenz Leadership Team
/in Announcements, Events, Featured /by Maris PanjadaAs Vice President, Strategic Enablement, Steenland appointed to accelerate value for Valenz clients
PHOENIX, Ariz. (April 9, 2021) — Vālenz® is pleased to announce the appointment of Maurice Steenland as Vice President, Strategic Enablement.
In his new role, Steenland will be responsible for synchronizing departments to accelerate strategic initiatives that bring greater value to Valenz clients, fulfilling the company’s strategic vision and mission. He will continue to drive the expansion of the firm’s data engagement solution, v-Lens, to advance predictive modeling, data-driven decision enablement and transparency across the ecosystem.
“We are excited to welcome Maurice to this key strategic role on our senior leadership team,” said Rob Gelb, Chief Executive Officer of Valenz. “With deep expertise in uncovering operational efficiencies and enabling data and analytics to inform better decisions, Maurice is an excellent fit for the Valenz team. His highly strategic and analytical approach will no doubt add higher levels of transparency across our data-driven ecosystem to deliver smarter, better, faster healthcare.”
Steenland brings 20-plus years in executive roles for health-related organizations. Most recently, he was principal consultant for SISIX, LLC after serving as Vice President, Informatics for Optum, where he managed the Informatics and advanced analytics and data science teams that developed client outcomes reporting, predictive tools and methods to identify emerging risk and cost containment programs.
Steenland also has held leadership positions at CIGNA Healthcare, Coventry Health Care and Intracorp, with specialization in operations, utilization management, strategy and business development. He earned his master’s in business administration from the prestigious Wharton School of the University of Pennsylvania.
“I’m thrilled to join such a future-focused team at Valenz and have the opportunity to pave the way toward quality, utilization and cost transformation through transparency, efficiency and data-driven solutions,” Steenland said. “As we combine analytics-driven approaches with influencing skills to drive change and efficiencies, I look forward to providing greater savings and solutions for our clients in the self-insured industry.”
About Valenz
Vālenz® enables self-insured employers to make better decisions that control costs across the life of a claim while empowering their members to lead strong, vigorous and healthy lives. Valenz connects cost and quality data from comprehensive care management services (Valenz Care), high-value provider networks (Valenz Access), claim flow management (Valenz Claim), complete bill review (Valenz ProteKHt), and solutions for payment integrity, revenue cycle management and eligibility compliance (Valenz Assurance) for smarter, better, faster healthcare. More information is available at valenzhealth.com. Valenz is backed by Great Point Partners.
Vālenz Announces Acquisition of Kozani Health
/in Announcements, Featured, Misc., Valenz Claim /by Adam LeeKozani Health integrates as ValenzProteKHt™ for complete and comprehensive bill review solution
PHOENIX, Ariz. (April 1, 2021) — Vālenz® announced today it has acquired Kozani Health, integrating a new and innovative means for self-funded employers and the self-insured community to control costs across the life of a claim.
Kozani Health, which provides customized solutions to meet the challenges of paying medical claims appropriately, joins the ever-expanding Valenz ecosystem of data and solutions as Valenz ProteKHt™. The new solution offers detailed line-by-line bill reviews performed by nurses, certified coders and practicing specialists to uncover inappropriate billing and care provided.
With success rates averaging 70 percent, Valenz ProteKHt is the industry’s recognized comprehensive and complete bill review solution. Valenz ProteKHt offers clear, defensible, transparent and plan-specific reviews that deliver savings of 10-30 percent above the PPO allowable with a signed contract, agreed upon and authorized by the provider.
“We are excited to welcome Kozani Health as part of our data-driven Valenz ecosystem,” said Rob Gelb, Chief Executive Officer. “By bringing our teams together, we are providing self-funded employers and the self-insured community improved cost savings at each step in the life cycle of a claim, strengthening their ability to realize every opportunity to balance cost, quality and utilization under the Claim Cost ArcSM. Our solutions aside, which clearly align value for all, our cultures and the commitment to customer service and ‘customer love’ will be a continuing defining characteristic of our now, collective success.”
Valenz is focused on changing the trajectory of healthcare expenses, creating new opportunities for self-insured employers to control costs while empowering members to lead strong, vigorous and healthy lives. Valenz delivers a 20-40 percent improvement in savings from traditional health plan approaches by bridging the divide between robust analytics, care management, high-value provider networks, payment integrity and claim management.
“We are energized to begin our company’s next chapter as Valenz ProteKHt,” said Michael Scott, Chief Executive Officer and Co-Founder of Kozani Health. “Integrating our claim management solutions into the Valenz ecosystem will accelerate the growth and evolution of our services and bring value to our customers.”
“With this integration, we assure clients they will experience the same close partnership and personal attention as they have with Kozani Health,” said Heather Wilson, Chief Operating Officer and Co-Founder of Kozani Health. “Now, we can also offer the benefit of being part of the Valenz ecosystem. Together, we are committed to nurturing the same ‘customer love’ that has made Kozani Health a symbol of success in the market.”
About Valenz
Vālenz® enables self-insured employers to make better decisions that control costs across the life of a claim while empowering their members to lead strong, vigorous and healthy lives. Valenz connects cost and quality data from comprehensive care management services (Valenz Care), high-value provider networks (Valenz Access), claim flow management (Valenz Claim), complete bill review (Valenz ProteKHt), and solutions for payment integrity, revenue cycle management and eligibility compliance (Valenz Assurance) for smarter, better, faster healthcare. More information is available at valenzhealth.com. Valenz is backed by Great Point Partners.
About Kozani Health
Kozani Health, headquartered in Mesa, Ariz., provides customized bill review sign-off and bill audit solutions to analyze pricing, coding and care provided to ensure appropriate payment. Since its inception in 2015, Kozani Health has forged long-term customer relationships and continuously improved solutions to solve customer challenges.
About Great Point Partners
Great Point Partners, founded in 2003 and based in Greenwich, CT, is a leading healthcare investment firm with approximately $1.3 billion of equity capital currently under management and 28 professionals, investing in the United States, Canada, and Western Europe. GPP is currently making new private equity investments from GPP III, which has $307 million of committed capital. Great Point manages capital in private (GPP I, $156 million and GPP II, $215 million of committed capital, and GPP III) and public equity funds. Great Point Partners has provided growth equity, growth recapitalization, and management buyout financing to more than 200 growing healthcare companies. The private equity funds invest across all sectors of the healthcare industry with a particular emphasis on biopharmaceutical services and supplies, pharmaceutical infrastructure, alternate site care, medical device and information technology enabled businesses. The firm pursues a proactive and proprietary approach to sourcing investments and tuck-in acquisitions for its portfolio companies. Reach Great Point at 203-971-3300 or www.gppfunds.com
Next Generation RBP Roundtable: Evolving Collaborative Approaches for a Balanced Reimbursement Strategy
/in Events, Featured, Misc. /by Adam LeeThe COVID-19 pandemic has had unprecedented impact on healthcare’s delivery, consumption and expense. While the use of virtual care has skyrocketed, 20 percent of U.S. households reported delaying care for serious problems during the pandemic, which can lead to major complications and catastrophic claims.
It is more important than ever for self-insured employers to have strategies in place that ensure their members are getting the right care, at the right time, from the right providers.
Vālenz® hosted a roundtable discussion focused on how the next generation of reference-based pricing programs focus on active collaboration between all parties to improve health outcomes while ensuring transparency.
Watch as Valenz CEO Rob Gelb and Adam V. Russo, Esq., Co-Founder and CEO of The Phia Group, discuss how innovative reimbursement strategies can bring balance to the quality-utilization-cost equation.
You will learn how the next generation RBP model integrates deep analytical insights with member-centric services to:
Click here to download a PDF of the slides.
Vālenz CaptiV: Reduce Risk, Gain More Control of Your Health Plan Spend
/in Announcements, Featured, Valenz Claim /by Adam LeeAs health care costs rise exponentially, self-insured employers are facing greater risks of high-dollar claims. Recognizing the significant risk-reduction advantages and cost-effectiveness of combining employer plans in a medical stop loss (MSL) group captive program, Vālenz® has launched CaptiV to solve the challenges market volatility can pose for small to medium-sized employers.
Valenz CaptiV goes beyond risk sharing to provide a fully integrated, data-driven model for cost and risk reduction. By bringing together employers that are committed to managing their medical costs while improving health outcomes – and equipping them to engage early and often via its end-to-end analytics platform – Valenz CaptiV represents the next generation of MSL group captives.
“We operate at the center of the MSL group captive, actively engaging the group of employers and their employees in our proprietary ecosystem of data and service solutions,” said Rob Gelb, Chief Executive Officer of Valenz. “Our analytic and predictive capabilities uncover new strategies to drive a 20-40 percent improvement in savings by targeting the high-dollar claims that drive the majority of health plan spending. We continually integrate those learnings among Valenz CaptiV members to reduce the potential for catastrophic claims and create value for everyone.”
For self-insured employers with fewer than 1,000 employees, Valenz CaptiV leverages a larger and more diverse population to reduce plan level and catastrophic risk, while delivering exceptional cost-reduction strategies, increased underwriting credibility, and long-term rate stability.
“For captive members, our ecosystem offers unparalleled data-driven collaboration. from pre-claim loss to post-claim resolution,” said Gelb, explaining, “Valenz solutions build on one another, providing actionable information at each step in the life cycle of a claim.”
To accelerate its captive offerings, Valenz partnered with MSL Captive Solutions, the industry’s only platform dedicated to the development and delivery of comprehensive services exclusively for MSL captives. MSL Captive Solutions works with top insurance carriers and claims administrators to deliver market-leading results for Valenz CaptiV members.
“Properly structured group captives have proved to reduce costs and increase plan stability by effectively managing, diversifying and broadly diffusing risk,” said Phil Giles, Managing Director of MSL Captive Solutions. “By taking a discerning approach to membership and enabling more active, data-driven risk management, Valenz CaptiV promises superior performance.”
Together, the firms offer more strategic, proactive risk control and cost-reduction decision-making. And, as costs are contained, Valenz CaptiV members share in the profitability of the program.
For more information on Valenz CaptiV, call (866) 762-4455.
About Valenz
Through a complete health administrative ecosystem, Valenz connects cost and quality data on a single-source, end-to-end analytics platform for smarter, better, faster healthcare. Valenz solutions integrate data from comprehensive care management services (Valenz Care), high-value provider networks (Valenz Access), claim flow management (Valenz Claim) and solutions for payment integrity, revenue cycle management and eligibility compliance (Valenz Assurance) into the ecosystem. More information is available at valenzhealth.com. Valenz is backed by Great Point Partners.
About Great Point Partners
Great Point Partners (“GPP”), founded in 2003 and based in Greenwich, CT, is a leading healthcare investment firm, currently with approximately $1.8 billion of equity capital under management and 28 professionals, investing in the United States, Canada and Western Europe. Learn more at www.gppfunds.com.
About MSL Captive Solutions, Inc.
MSL Captive Solutions is the industry’s only platform devoted exclusively to the development of comprehensive (re)insurance solutions for group and single-parent medical stop loss captives.
MSL Captive Solutions provides consultative underwriting support to some of the industry’s leading stop loss carriers and operates independently to work with all qualified brokers, consultants, and captive managers. For more information visit www.mslcaptives.com.
Four Solutions to Support Employees’ Mental Health During COVID-19
/in Featured, Valenz Care /by Adam LeeThis article is third in our series examining how the self-insured industry can respond to the long-term effects of COVID-19 on member health.
The COVID-19 pandemic has impacted almost every part of our daily lives, including physical, financial and emotional health. As the pandemic continues to worsen, we are gaining greater visibility into emerging mental health issues among the U.S. population. Consider these recent statistics:
Mental health claims within our ecosystem are significantly on the rise, and clients are reporting increased concern about pandemic-related effects on their employees – adding new life to discussion about modifying care delivery models. The healthcare industry is acknowledging the significant correlations between physical and mental health, traditionally cared for as separate conditions. Integrated care solutions that treat the whole person could deliver improved outcomes with less expense.
To that end, in the face of continuing upheaval and stress from COVID-19, what resources can self-insured employers offer to support their employees? Here are four solutions to consider:
1: Use data to identify members at risk.
Employers are increasingly turning to data to identify employees at risk and proactively offering them the resources they need. Today’s technologies are providing new insights by leveraging real world data (RWD), which refers to health-related information collected and reported by diverse sources on patient health status, population trends and the routine delivery of care.
Within an ecosystem like ours, RWD come from multiple sources including electronic medical and health records, claims and case management databases – even from employees themselves. We anticipate self-assessments, social media and health-related wearables as emerging data sources that will soon be added into the mix to more precisely predict those in need of behavioral health services.
2: Offer a care management program with personalized support and navigation.
Poor mental health and behavioral choices make physical health and chronic care conditions more challenging and expensive to manage. To meet the patient’s physical and mental health needs, comprehensive care management involves the active monitoring of behavioral health to help prevent serious health events and navigate care across multiple providers and settings.
A full-service care management program with a nurse navigator as a central point of contact can personalize its services for employees who may benefit from more comprehensive attention. As they coordinate care and guide patients to an individualized treatment plan for better behavioral health, nurse case managers can help relieve anxiety and make at-risk patients feel more in control and proactively managing their health.
3: Ensure networks provide access to mental health services with telehealth options.
Demand for behavioral health services is expected to stay high for the foreseeable future. According to the National Alliance on Mental Illness (NAMI), however, many people do not have the same access to mental health specialists as they do for other medical providers – nor do they have as many available options. When they can find a mental health professional, they may be forced to go out of network to receive treatment.
This leads to higher out-of-pocket costs for mental health care compared with other types of primary or specialty care. When people face increased expenses, it may lead to seeking less care — or going without any care at all. Access to mental health services, clearly communicated to employees, is key to seeking and receiving treatment, which in turn improves productivity and retention.
A coordinated care team is better able to meet both the mental and physical health needs of the patient with improved outcomes. Along those lines, the American Medical Association has established the Behavioral Health Integration (BHI) Collaborative with seven other physician associations to promote the integration of behavioral and mental health care into primary care practices. Such steps are critical for greater access and a robust telemedicine plan that addresses the issue of fewer available mental health providers by incorporating primary care into the solution.
4: Include an Employee Assistance Program in your benefits package.
People are struggling more than ever in the wake of COVID-19. An Employee Assistance Program (EAP) provides confidential support for numerous concerns, including mental health issues and personal, family or work problems. Counselors and other specialists can assist with stress, depression, substance abuse or financial issues. Identify an EAP that responds quickly when employees reach out.
The benefits of an EAP make such a program a worthy investment. NAMI estimates that untreated mental illness costs the United States up to $193 billion annually in lost productivity.
When employees are able to successfully manage their health, employers can expect to see improved job performance, productivity, engagement and retention; while minimizing the impact to their bottom line due to turnover, absenteeism, increased mental health services and higher insurance costs.
Data-driven solutions
The COVID-19 pandemic has forced all of us to find new solutions for improved health and access to the right care delivery. Through the mental, physical and financial implications of this global health crisis, Valenz remains committed to delivering on our core promise of smarter, better, faster healthcare – so our clients and their employees are strong, vigorous and healthy.
***
Amy Gasbarro is Chief Operating Officer of Vālenz™, one of the nation’s leading data-driven, medical cost containment and care management organizations offering an ecosystem of expanded data and service solutions to support the self-insured industry.
Vālenz Appoints Dorshorst, Onion to Leadership Team
/in Announcements, Events, Featured /by Maris PanjadaNew Vice Presidents Poised to Enhance Data-Driven Solutions, Cost Savings and Operational Excellence
PHOENIX, Ariz. (December 4, 2020) — Vālenz™ is pleased to announce the appointments of Randy Dorshorst and Patty Onion to the leadership team.
Dorshorst has joined Valenz as Vice President, Ecosystem Success, to advance the innovation behind the company’s health administrative ecosystem, combining data analytics with care service delivery to minimize claims costs for the self-insured industry and promote quality care.
“We are thrilled to welcome Randy to our senior team to oversee the continuing success of our product, data and client program solutions,” said Rob Gelb, Chief Executive Officer. “Randy offers 30 years of expertise in driving growth, technology and value through custom solutions, which makes him an outstanding fit to lead Valenz in the purposeful expansion of our ecosystem.”
Most recently, Dorshorst served as Vice President for AViDEL Medical Management in Irving, Texas. With his comprehensive leadership and management skills, he directed the successful launch of AViDEL as a sister company to Service Lloyds Insurance Company, where he was Vice President for Medical Management Service. Dorshorst also has held executive positions at HealthSmart Casualty Claims Solutions, Web TPA and CorVel Corporation.
Onion, who has more than 30 years’ experience in workers’ compensation, medical cost containment and managed care, joins Valenz as Vice President, Claim Operations.
“Patty’s proven success in setting strategic direction and implementing managed-care platforms and services makes her uniquely well-positioned for this role,” said Amy Gasbarro, Chief Operating Officer of Valenz. “She brings tremendous expertise in claim operations and process improvements that will help us go even farther to drive results for our clients and offer the highest possible level of service.”
Onion most recently served as principal for Milana Health Systems in Kansas City, Mo., specializing in workers’ compensation managed-care consulting. She was CEO of Berkley Medical Management Solutions and has held executive roles with numerous health-related companies including Coventry Health Care, Premera Blue Cross and Mercy Health Plan.
“I have been fortunate to know Patty and Randy for years, and most recently we have benefited from their guidance and counsel as consultants to Valenz,” Gelb said. “Today, I couldn’t be happier to have them on board full time, as they both bring outstanding leadership and deep expertise that will empower us to further deliver on our promise of smarter, better, faster healthcare.”
About Valenz
Through a complete health administrative ecosystem, Valenz connects cost and quality data on a single-source, end-to-end analytics platform for smarter, better, faster healthcare. Valenz solutions integrate data from comprehensive care management services (Valenz Care), high-value provider networks (Valenz Access), claim flow management (Valenz Claim), and solutions for payment integrity, revenue cycle management and eligibility compliance (Valenz Assurance) into the ecosystem. More information is available at valenzhealth.com. Valenz is backed by Great Point Partners.
About Great Point Partners
Great Point Partners (“GPP”), founded in 2003 and based in Greenwich, CT, is a leading healthcare investment firm, currently with approximately $1.8 billion of equity capital under management and 28 professionals, investing in the United States, Canada and Western Europe. Learn more at www.gppfunds.com.
Searching State Exclusion Lists: Why It Matters for Assured Compliance
/in Featured, Valenz Assurance /by Adam LeeIf your profession involves compliance management, you know the Office of Inspector General’s List of Excluded Individuals/Entities (OIG LEIE) is the federal database for all Medicaid sanctions – and no doubt your team checks it regularly for sanctioned providers. However, many investigations are conducted by state Medicaid offices and do not always include federal participation. Is your compliance team checking for sanctions and exclusions at the state level as well? If not, they should be.
In fact, OIG Best Practices state that you should also search every state sanction and exclusion list that corresponds with your business or service delivery location(s) – meaning, all states where you operate or have a physical business presence. Some organizations are required to check all 41 state Medicaid sanction lists, but if yours is not one of them, our compliance experts recommend at least checking border states and any other state where the providers in your network or health system have practiced in the past.
Why? Because state actions may appear before federal listings, and in some cases, the states and federal databases do not fully synchronize their entries. But, to be clear, if a person or organization you do business with is excluded by your state, you will face the full threat of repercussions, for hiring and reimbursing them, even if they do not appear on the federal exclusion list.
What do those repercussions look like? In addition to the loss of your reimbursement funds plus interest, civil monetary penalties may apply – not to mention reputational damage and potential legal liability. When it comes to non-compliance, the risks and penalties can be great, so the time and costs associated with checking every applicable sanctions and exclusion list, including state lists, is well worth it.
Also worth noting: To screen thoroughly, you must search lists from state licensing and medical boards, as well as state and county disciplinary action lists and abuse registries (including state/local consumer affairs, addiction recovery lists and more). Checking all lists, not just the major ones, helps ensure compliance by alerting you to providers who may have had fines imposed or faced certain allegations but have not formally been sanctioned.
If you don’t have the internal manpower to ensure no stone is left unturned, good news: Affordable outsourcing options are available. At Vālenz Assurance, we offer a range of compliance software and support solutions to meet your needs and budget. To learn more about how we take the complexity out of compliance, call 888-395-9029.
Building an Effective Compliance Management Program: What You Need to Know
/in Featured, Valenz Assurance /by Adam LeeTo help prevent fraud and abuse – and all the punitive setbacks that come with broken health care laws and unmet regulations – having a robust compliance program is key. There is no one-size-fits-all approach to compliance management, however, and it is most effective to tailor your program to your organization’s structure and type. The following FAQs are designed to help you understand the basics and formulate next steps for your compliance program.
What is a compliance program, and why do I need one?
A compliance program is a set of internal policies and procedures that helps your organization comply with the law in its daily operations. A proactive plan helps you maintain compliance with today’s regulations, as well as providing a framework for implementing future requirements.
What are the basic components every compliance program should include?
Effective compliance programs include these essential components:
Why should I customize my organization’s compliance program?
Every organization is structured differently, has unique staffing and contracting programs, provides a different mix of services, and has a specific profile of patient demographics and payer mix. While the basic essentials apply to any compliance program, the specifics will vary based on your organization’s unique operations, structure, and areas of risk.
What resources are available to help me customize my compliance program?
To help you develop a compliance program that is most impactful for your organization, the Office of Inspector General (OIG) has developed a set of principles, called Compliance Program Guidance (CPG). These guidance documents are geared toward different segments of the healthcare industry, including:
Use the CPGs as a starting point, and then tailor them for your organization. The OIG provides many additional compliance resources to encourage effective internal controls to monitor and manage adherence to applicable statutes, regulations, and program requirements.
Also, remember that a compliance program is never done – it evolves with your business and with changing regulations. It is forward-looking, and focused not only on risk containment, but also on best care and management practices.
This sounds like more than my small team can manage. Can I outsource my compliance program instead?
Yes! At Vālenz™, we offer a range of compliance software and support solutions to help assure you are not the “last to know” about a sanctioned provider or other compliance issue. With three tiers of service to accommodate any need and every budget, we take the complexity out of compliance and deliver peace of mind. To learn how we help you protect your organization from the risks of non-compliance, call 888-395-9029.
The Effects of COVID-19 on Chronic Disease Management – and Five Solutions Insurers Should Embrace
/in Announcements, Featured /by Maris PanjadaThis article is second in our series examining the long-term impact of COVID-19 on health and healthcare issues for the self-insured industry.
Chronic conditions are the leading cause of death in the United States, as well as the primary driver of our $3.5 trillion annual healthcare costs. Long before COVID-19 hit, providers, payers and self-insured employers grappled with the challenge of ensuring that patients with chronic illnesses receive effective care.
Recent surveys indicate many patients have put their chronic care needs on hold during the pandemic, potentially leading to more expensive scenarios in the future. Consider these findings from a recent survey:
Even with heightened safety precautions that have made office visits and routine care widely available again, many patients have been slow to return – especially for people with long-term conditions like asthma, heart disease and diabetes, who are at significantly higher risk of severe illness from COVID-19.
As the health industry adapts to consumerism by adapting care deliver to meet the evolving needs of consumers, so too must payers and self-insured employers. Here are five solutions that take significant steps towards improving service and care for chronic disease patients during the pandemic and potentially beyond:
1: Telehealth and virtual care
Expanded telehealth access has been the key component of the rise of virtual care utilization, allowing care continuity while all parties maintain physical distancing. Combined efforts by the federal government, individual states, private insurance companies and self-funded groups have facilitated telehealth as a viable care option during the pandemic, lowering regulatory barriers that had limited its use and the reimbursement of services. According to the American Medical Association, physician telehealth adoption is now estimated at 60-90 percent.
In addition, a survey by Accenture in July 2020 reported that providers were largely able to maintain or even improve on the patient experience with virtual care technology, which also includes live video, audio and instant messaging. With 41 percent of respondents taking advantage of virtual tools – the majority of them for the first time ever – patients reported more personal interactions, faster response times, and the convenience of managing care from home. Virtual care and telehealth are proving especially useful for chronic disease patients in rural and remote areas.
2: Patient-centric care navigation
For self-insured employers, brokers and third-party administrators, care-coordination solutions like NaVcare help members navigate their health journey more effectively, delivering personalized service and guidance for high-quality care and improved outcomes. Real-time data-driven insights, combined with in-depth health plan knowledge, are critical for identifying patients with complex, chronic conditions. Providing those patients with comprehensive care management helps avoid more serious and costly health events.
Informed by data – including claim, pharmaceutical and demographic data –NaVcare tailors services to each employer and illuminates individual care needs for members. Care navigators facilitate virtual care when available for enhanced patient convenience and engagement as well.
3: Behavioral health integration
People with chronic diseases are more likely to experience depression or behavioral issues as they often face impaired mobility and loss of independence. According to the Center for Medicare Advocacy, 43.8 million U.S. adults struggle with mental illness each year, and 26 percent of those are Medicare beneficiaries – a population that is highly vulnerable to the effects of isolation, increased stress and more limited access to regular care, even before the pandemic.
Traditionally, the care delivery models to address physical and behavioral health have been independent of each other. More and more, providers and health organizations are acknowledging the significant correlations between physical and mental health, turning to integrated care solutions that treat the whole person and deliver improved outcomes with lower costs – up to 10 percent savings in the nation’s overall healthcare expenses, according to the American Psychiatric Association.
4: Prescription cost management
Following a national trend that has continued for the past decade, costs have risen for chronic disease medications and depression/anxiety drugs during the pandemic, with total prescription spend predicted to reach $610 billion in 2021. Before COVID-19, one in three Americans did not take their medications as prescribed because of high costs, but during a global pandemic, forgoing medications involves even more risks for chronic care patients and incurs even higher costs in the long run.
Cost-containment solutions for self-insured employers, brokers and third-party administrators include a range of PBM solutions and specialty medication case management services. Such solutions create long-term reductions in medication spend while passing on lower costs to members and delivering highly personalized case management services and advocacy.
5: Remote patient monitoring
Recent studies connecting COVID-19 to long-term heart and lung damage, among other serious conditions, accentuate the benefits of remote monitoring technologies for high-risk patients. As it tracks and transmits vital signs in real time, remote patient monitoring allows providers to regularly check pulmonary function, blood pressure, body temperature and other physiology for proactive management of changes in disease progression.
A joint report from AHIP, the national association of America’s Health Insurance Plans, and C-TAC, the Coalition to Transform Advanced Care, concludes that remote patient monitoring is among the most efficient and effective tools available to manage chronic disease — particularly in older patients with diabetes, heart failure, and chronic obstructive pulmonary disease.
Solutions for today and tomorrow
Patients with chronic illnesses are more vulnerable to some of COVID-19’s most significant threats. As the global health crisis continues to present new challenges in treating patients with long-term conditions, it also has opened up new opportunities. It is exciting to be part of the evolution of solutions that will serve patients well beyond the pandemic – showing us all the next level of smarter, better, faster healthcare.
***
Rob Gelb is Chief Executive Officer of Vālenz™, one of the nation’s leading data-driven, medical cost containment and care management organizations offering expanded solutions to support the self-insured industry.
About Valenz
Through a complete health administrative ecosystem, Valenz connects cost and quality data on a single-source, end-to-end analytics platform for smarter, better, faster healthcare. Valenz solutions integrate data from comprehensive care management services (Valenz Care), high-value provider networks (Valenz Access), claim flow management (Valenz Claim) and solutions for payment integrity, revenue cycle management and eligibility compliance (Valenz Assurance) into the ecosystem. More information is available at valenzhealth.com. Valenz is backed by Great Point Partners.
About Great Point Partners
Great Point Partners (“GPP”), founded in 2003 and based in Greenwich, CT, is a leading healthcare investment firm, currently with approximately $1.8 billion of equity capital under management and 28 professionals, investing in the United States, Canada and Western Europe. Learn more at www.gppfunds.com.
Vālenz™ Access Assured: An Integrated, Dynamic Approach to Reference Based Pricing
/in Announcements, Featured, Valenz Access /by Maris PanjadaPHOENIX, Ariz. (Oct. 15, 2020) – Employers and private health plans pay hospitals nearly 2.5 times more than Medicare, according to a recent study by the RAND Corporation. And while employers and their members pay more each year, researchers found no strong link between hospital pricing and healthcare quality or safety ratings. To manage rising medical costs while improving health outcomes, self-insured employers need solutions which definitively balance the cost-quality equation.
To answer that growing need, Valenz Assured Access provides an integrated, dynamic approach to reference based pricing. As the innovators behind a comprehensive ecosystem designed to effectively bend the Claim Cost Arc℠ for payers and improve patient experiences for members, Vālenz™ has established a next generation RBP model that integrates deep analytical insights with member-centric services while collaborating with providers and payers to ensure transparency.
Using the proprietary VMS℠ Repricing Methodology, Valenz Access Assured blends payment, cost and charge data sets to produce reimbursement recommendations that are fair, defensible, transparent and consistent for everyone.
“VMS recognizes that not all Current Procedural Terminology (CPT) codes or services delivered in healthcare have a Medicare rate, so we incorporate two additional data sources – paid claim data and Usual, Customary, Reasonable (UCR) data – to provide a more structured and defensible reimbursement recommendation,” said Rob Gelb, Chief Executive Officer. “When leveraging these sources of data, we offer our customers a more robust and well-rounded view of reasonable reimbursement levels.” Supporting a consistent and substantiated reimbursement model not only reduces costs, Gelb explained, it reduces friction among the payer, provider and patient.”
With Valenz Access Assured, member-centric coordination begins at the outset of care, where dedicated care navigators serve as the central point of contact for all stakeholders. Through NaVcare, members receive concierge-level guidance as well as the URAC-accredited care management services of Valenz Care. As a result, members are guided toward high-quality care and empowered to make better health decisions that control costs, improve health outcomes and elevate the member experience.
Provider collaboration also starts before care delivery. The Valenz Assured Access team engages providers and facilities in pre-service negotiation to procure contractual agreements before services are rendered, creating transparency of cost and eliminating the risk of balance billing. From there, a Valenz contracting expert works to secure a long-term agreement, continually supporting the plan and members through high-value network development and expansion, direction of care and high-quality provider utilization.
When contracting is not an option and a provider appeals reimbursement levels, Valenz Assured Access protects the member and the plan with comprehensive support, including negotiations with the provider and legal advocacy.
“We designed all program components with the member in mind, following our guiding philosophy that everyone who engages with the Valenz ecosystem should be strong, vigorous and healthy,” said Amy Gasbarro, Chief Operating Officer. “Ease of access to high-quality providers, appeal support, development of new provider agreements and next-generation pricing models – these approaches integrate seamlessly to deliver on our core promise: engaging early and often for smarter, better, faster healthcare.”
About Valenz
Through a complete health administrative ecosystem, Valenz connects cost and quality data on a single-source, end-to-end analytics platform for smarter, better, faster healthcare. Valenz solutions integrate data from comprehensive care management services (Valenz Care), high-value provider networks (Valenz Access), claim flow management (Valenz Claim) and solutions for payment integrity, revenue cycle management and eligibility compliance (Valenz Assurance) into the ecosystem. More information is available at valenzhealth.com. Valenz is backed by Great Point Partners.
About Great Point Partners
Great Point Partners (“GPP”), founded in 2003 and based in Greenwich, CT, is a leading healthcare investment firm, currently with approximately $1.8 billion of equity capital under management and 28 professionals, investing in the United States, Canada and Western Europe. Learn more at www.gppfunds.com.