The move to value-based care in the State of Arizona will accelerate in the future and Equality Health is there to help our clients manage the transition. To support AHCCCS, CMS, and our Health Plan partners, Equality has assembled a formidable team of risk delegation experts, provider services, population health technology, and managed care services to create deeper partnerships between providers and plan sponsors.

A delegation of financial risk allows a managed care plan to share risk with a delegate, creating system stability and a reasonable division of administrative and clinical management. Equality Health’s Q Point Coordinated Care Organization is well positioned to support both payer and providers, by aggregating providers for payer administrative simplification, and, at the same time, aggregating payer requirements for provider simplification.

Being an independent entity not owned by a health plan or a hospital, we can help support the confidential sharing of data and negotiation of contracts among the entities engaged in a delegated risk contract.

Working with our managed care partners, we collaborate to discern the appropriate risk structure for the targeted population we are asked to serve. Equality Health can provide risk management services, from a simple share of savings plan to full risk-bearing global capitation and percent of premium contracts. We work closely with 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 with closely with our Health Plan partners through the delegation of financial risk (DOFR) process and offer delegation services in the following areas:

  • Utilization Management/Prior Authorization
  • Provider Credentialing
  • Cultural Care/Case Management
  • Claims Payment

Preauthorization and Utilization Management

Q Point’s 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 ensure that the treatment is the most appropriate and cost effective. We use our Health BI CareEmpower platform to analyze data and provide daily updates on our highest risk and emerging risk patients to better control costs earlier in the care process.

Through our PA/UM program, we are able to provide significant savings through:

  • Management and redirection of out-of-network procedures
  • Avoidance of unnecessary hospital stays
  • Technology-driven automated discharge and care transitions
  • Improved care coordination and information exchange
  • Denial of services if they are not medically necessary or are a plan exclusion

Provider Credentialing

Q Point utilizes the CAQH ProView 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 provide accredited National Committee for Quality Assurance (NCQA) credentialing standards and work closely with our payer clients to maintain compliance and eliminate deficiencies in the credentialing process.

Cultural Care/Case Management

If contracted for our cultural care management program, Q Point will assign our highly-specialized bi-lingual case and care managers trained in cultural competence and our proprietary cultural care pathways. Our cultural care managers have community-based relationships that can engage the full welfare of the patient, in addition to the clinical needs of the patient.

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. This comprehensive support is tailored to fit the individual member health needs.

Patients are first identified by our risk stratification and predictive analytics through the Health BI CareEmpower platform. By layering in member/patient care alerts, cultural assessment data, and risk scores, we have a 360-degree view of our high-risk and emerging risk patient profiles and up-to-date registries for actionable 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 include:

  • Cancer
  • Congestive Heart Failure
  • Traumatic injuries
  • Organ failure
  • Transplants
  • High-risk pregnancy
  • Complex medical diagnoses

Once a patient is actively case managed, the care/case manager works closely with the patient and the integrated care team to align the benefit plan to ensure that the patient receives appropriate care and takes preventative measures to avoid higher cost services.

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 claims analysis and real-time alerts
  • Utilization Management
  • Identification of preventative services that are culturally appropriate
  • Patient stabilization
  • Coordination of care with all caregivers
  • Patient advocacy and mobile engagement
  • Stop loss notifications to client-specified parties

Claims Payment

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
+ Management/Authorization

Preauthorization and Utilization Management

Q Point’s 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 ensure that the treatment is the most appropriate and cost effective. We use our Health BI CareEmpower platform to analyze data and provide daily updates on our highest risk and emerging risk patients to better control costs earlier in the care process.

Through our PA/UM program, we are able to provide significant savings through:

  • Management and redirection of out-of-network procedures
  • Avoidance of unnecessary hospital stays
  • Technology-driven automated discharge and care transitions
  • Improved care coordination and information exchange
  • Denial of services if they are not medically necessary or are a plan exclusion
+ Credentialing

Provider Credentialing

Q Point utilizes the CAQH ProView 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 provide accredited National Committee for Quality Assurance (NCQA) credentialing standards and work closely with our payer clients to maintain compliance and eliminate deficiencies in the credentialing process.

+ Care & Management

Cultural Care/Case Management

If contracted for our cultural care management program, Q Point will assign our highly-specialized bi-lingual case and care managers trained in cultural competence and our proprietary cultural care pathways. Our cultural care managers have community-based relationships that can engage the full welfare of the patient, in addition to the clinical needs of the patient.

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. This comprehensive support is tailored to fit the individual member health needs.

Patients are first identified by our risk stratification and predictive analytics through the Health BI CareEmpower platform. By layering in member/patient care alerts, cultural assessment data, and risk scores, we have a 360-degree view of our high-risk and emerging risk patient profiles and up-to-date registries for actionable 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 include:

  • Cancer
  • Congestive Heart Failure
  • Traumatic injuries
  • Organ failure
  • Transplants
  • High-risk pregnancy
  • Complex medical diagnoses

Once a patient is actively case managed, the care/case manager works closely with the patient and the integrated care team to align the benefit plan to ensure that the patient receives appropriate care and takes preventative measures to avoid higher cost services.

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 claims analysis and real-time alerts
  • Utilization Management
  • Identification of preventative services that are culturally appropriate
  • Patient stabilization
  • Coordination of care with all caregivers
  • Patient advocacy and mobile engagement
  • Stop loss notifications to client-specified parties
+ Claims

Claims Payment

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

Request an Appointment

For more information about Equality Health Network or to schedule an appointment with one of our physician advocates contact us:

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