Managed Care Contracting and Regulatory AnalysisOctober 12, 2016
A client engaged EBG Advisors for assistance with their managed care arrangements with health plans and network providers, requesting review, regulatory analysis and any required template agreement updates and/or drafting. The engagement involved state- and federal-level managed care statutory and regulatory analysis; managed care agreement template development, review and analysis; and ongoing communication with the client, state agencies, and other key stakeholders.
EBG Advisors spearheaded the update and development of standard template agreements after providing a thorough analysis of existing managed care and network contract templates and relevant state and federal requirements. EBG Advisors also provided review, analysis and drafting support to the client, specifically with regard to the managed care and third party administrator agreements that had been developed to engage managed care organizations, provider networks, and management services entities.
Integrated Delivery System for Dual EligiblesOctober 10, 2016
EBG Advisors has explored the Maryland health care landscape to help the state's Medicaid agency understand the opportunities and challenges of different pathways to coordinating care of individuals dually eligible for Medicare and Medicaid. Efforts included examining other states’ approaches and, in particular, considering a unique approach relying upon accountable care organizations (ACOs). EBG Advisors also facilitated the deliberations of a workgroup comprised of 25 representatives of consumers, providers, health plans and other stakeholders. We have guided the agency on choosing its strategy, produced content for the workgroup’s consideration, educated the workgroup members, and led the group’s monthly in-person meetings. EBG Advisors has also joined substantively in the agency’s meetings with the CMS Innovation Center to discuss the options and federal approval requirements.
To date, the project has yielded a conclusion on a hybrid model for duals (ACOs in areas of high population density, managed fee-for-service elsewhere) and tentative agreement with CMS on a waiver pathway toward implementing the model.
Implementation of National Health InsuranceAugust 1, 2016
EBG Advisors successfully assisted the second Caribbean country to implement National Health Insurance (NHI), a single-payer system designed to ensure that all citizens have access to health care.
The Caribbean island nation of the British Virgin Islands (BVI), with a population of 32,000, had a plan on paper to institute a NHI program covering the entire population. The government also had purchased a license to claims processing software. What the BVI government lacked was the know-how and full complement of personnel to actually stand up the program and run it. The government also required assistance in recruiting health care providers to participate in NHI.
Thanks to persistent effort by Cliff Barnes and Bob Atlas, as well as local support by Amos Carty, EBG Advisors was engaged to assist fully with NHI implementation. The period from the date of contract execution to going live was approximately nine months.
Specifically, EBG Advisors deployed a multidisciplinary team of health insurance policy and operations experts, comprised of both internal staff and consultants from our partner BluePeak Advisors. The team executed the engagement in two stages. First, a gap analysis was conducted to identify the elements needed for successful NHI implementation and the state of readiness at the start of the project. The gap analysis yielded a work plan for our team.
Second, the team executed the work plan by: preparing contracts for NHI with private and public health care providers, and drafting the provider manual; creating a provider fee schedule and a provider credentialing process; meeting directly with providers to explain the program; devising and documenting medical and pharmacy benefit management policies, business rules, and forms for the totality of the program; developing the structure of the relationship between the Health Service Authority and NHI; collaborating with the claims software vendor to translate the policies and business rules into the system; evaluating proposals for reinsurance and overseas specialty referral networks; proposing an organizational chart with staffing needs, and drafting job descriptions for all roles; training staff in the requirements of their jobs; and assisting in resolving unforeseen issues during the critical go-live period.
Post-implementation, EBG Advisors also assisted in developing NHI’s Compliance Program.
BVI’s NHI successfully began operation on January 1, 2016, and NHI program staff members are functioning self-sufficiently at present.