The move to value-based care in the State of Arizona will accelerate in the future and Equality Health will help its clients manage the transition. To support AHCCCS, CMS, and our health plan partners, Equality Health has assembled a formidable team of risk-delegation experts, along with provider services, population health technology, and managed care services to create deeper partnerships between providers and plan sponsors.
Delegated Risk Services
Transitioning to Value-Based Care
Delegation starts with trust.
A delegation of financial risk allows a managed care plan to share risk with a trusted partner, creating system stability and a reasonable division of administrative and clinical management. Q Point Health is well positioned to support both payers and providers, by organizing providers into one network for payer administrative simplification, and, at the same time, combining multiple payer requirements into one platform that reduces provider burden.
Being an independent entity not owned by a health plan or a hospital, Equality Health supports the confidential sharing of data and negotiation of contracts among the entities engaged in a delegated-risk contract.
Offering a full array of risk-management services.
Working with our managed care partners, we collaborate to identify the appropriate risk structure for the populations we are asked to serve. Equality Health provides a full array of risk-management services, from a simple share of savings plan to full risk-bearing global capitation and percent of premium contracts. To achieve this, we work closely with our managed care clients to define the necessary funds flow scheme, stop-loss insurance, encounter reporting, and provider incentive payment documentation to ensure transparency, regulatory compliance, and delegation governance.
We work closely with our health plan partners and offer delegation services in the following areas:
- Prior Authorization/Utilization Management
- Provider Credentialing
- Cultural Care/Case Management
- Claims Payment
Preauthorization and Utilization Management
Q Point’s Preauthorization and Utilization Management (PA/UM) program was established to identify, manage and mitigate clinical episodes for the populations we manage. This program enables us to understand and apply the medical necessity of the services a patient may receive and ensures that the treatment is the most appropriate and cost effective. We use our HealthBI CareEmpower® technology platform to analyze data and provide daily updates on our high-risk and emerging-risk patients to better control costs earlier in the care process. This information is shared directly with our providers as they are fully connected to Equality Health via the platform.
Through our PA/UM program, we are able to provide significant savings through:
- Management and redirection of out-of-network procedures and preventable specialist utilization
- Avoidance of preventable hospital stays
- Individualized and technology-driven discharge and transition-of-care planning
- Improved care coordination and information exchange
Q Point utilizes the CAQH ProView, which offers new features that make it easier for providers to make updates, reducing the time and resources necessary to submit accurate, timely data to organizations that require that information. Time-saving features enable healthcare providers to:
- Complete and attest to multiple state credentialing applications in one intelligent workflow design
- Upload supporting documents directly into CAQH ProView to eliminate the need for manual submission and to improve the timeliness of completed applications
- Review and approve practice manager information before data is imported
- Protect against delays in data processing with more focused prompts and real-time validation
- Self-register with the system before the application process
We adhere to National Committee for Quality Assurance (NCQA) and URAC credentialing standards and work closely with our payer clients to maintain compliance and eliminate deficiencies in the credentialing process.
Cultural Care/Case Management
Our comprehensive care model is designed to provide individualized care that is holistic and person-centered. When contracted for our cultural case management program, Q Point assigns our highly-specialized bilingual case and care managers, including behavioral health professionals, trained in cultural competence and our proprietary cultural care pathways. Our cultural care managers have community-based relationships that address the full welfare of the patient, in addition to clinical and behavioral needs.
Our care management team is organized as an interdisciplinary care team that consists of all the care management professionals that interact with the member/patient. Since this team uses HealthBI’s CareEmpower® platform, providers have full transparency into the care management of their members.
Delivering a 360° patient view.
High-needs members are identified by our risk stratification and predictive analytics through HealthBI’s CareEmpower® platform. By layering in member/patient utilization care alerts, Equality Health’s proprietary cultural assessment data, and health-risk scores, we have a 360-degree view of our high-risk and emerging-risk patient profiles. We then develop actionable interventions and care plans that create a higher-quality “yield” than traditional risk stratification methods.
Working with our PA/UM department we utilize this information to assign case management staff to the patient, to monitor the patient care and status. A variety of illnesses and complications are covered under Q Point’s program including:
- Complex and chronic conditions
- Behavioral health
- Personalized diabetes management
- Congestive heart failure
- Maternal care and high-risk pregnancies
Proactive measures start with preventive care.
Through the use of the following proactive measures, we are able to simultaneously promote a high standard of care and significant cost savings to the member and plan.
- Early identification through Equality Health risk stratification and real-time acute-care alerts
- Screening for behavioral co-morbid conditions
- Utilization management
- Identification of preventative services that are culturally appropriate
- Coordination of care across a continuum of providers and community resources
- Information sharing with Equality Health providers via HealthBI’s CareEmpower platform
- Patient advocacy with mobile chat, text and virtual engagement
- Stop-loss notifications to client-specified parties
Q Point will assist members by providing TPA services such as medical and claims management, data analytics, customer service and financial management. Third-party administrative functions for risk-based contracts include:
- Enrollment/eligibility and member benefits administration
- Provider relations and network development
- Claims imaging, adjudication, encounters and payment
- Grievance and appeal procedures
- Call center inbound and outbound services
- Financial, accounting, and audit
- Transition planning and implementation
- Marketing, printing, and fulfillment
Be ready for value-based care.
Questions about the transition to value-based? Use the form to the right to contact one of our experts.