Author: LBodnarchuk

Q & A with our new Managing Director, Tim Calhoun

Written by LBodnarchuk on . Posted in Insights.

ProspHire proudly welcomes Tim Calhoun as our newest Managing Director, bringing with him over two decades of invaluable healthcare experience. Formerly from Ernst & Young (EY), Tim has been instrumental in serving healthcare clients across commercial, nonprofit and governmental sectors. His decision to join ProspHire underscores our commitment to excellence in healthcare consulting. Tim’s wealth of knowledge will undoubtedly elevate our client offerings and our standing as industry leaders. Today, we are diving into Tim’s motivations for choosing ProspHire, his strategic vision for leveraging his healthcare experience to drive growth and his unwavering dedication to delivering exceptional project outcomes for our clients.

Can you share more about your background and what led you to join ProspHire as Managing Director?

I started out in accounting and auditing in both manufacturing and financial services industries; my undergraduate degree was in accounting from Penn State. I obtained my Executive MBA from Pitt and coming out of graduate school I was drawn to consulting because of the variety of opportunities and the challenge of working with clients on key initiatives that are important to them and their stakeholders. For most of my career, I have been involved with clients from regulated industries, financial services and utilities but making the decision to focus on healthcare required me to double down on understanding the industry and figuring out how to apply my earlier learnings and experience to a new space – what I refer to as pivoting.

What attracted me to ProspHire was the 100% focus on healthcare and when I arrived, it was the caliber of the people and their knowledge and experience that reinforced that I made the right decision. The entrepreneurial spirit, the culture and the ability to make quick decisions were also attractive.

Up until joining ProspHire, I spent my consulting career with global firms. In 2010, I had the opportunity to help rebuild a health practice, which I enjoyed a great deal. Because of that experience, I knew that if I were to make a change, I wanted to change it up. I found that with ProspHire – a focus and energy on healthcare, an entrepreneurial environment and an opportunity to have impact on building the next generation of leadership.

How do you envision leveraging your experience to help drive the strategic vision of ProspHire?

There is such a solid foundation and forward momentum to build upon. One of the key reasons for making the move to ProspHire was the opportunity to contribute to defining the future direction – understanding the strengths of the firm, envision the direction of our industry and how we can best help our clients and our teams achieve success. The leadership team is dedicated to our clients’ success, prioritizing support for our internal teams and leveraging our collective experiences to develop best practices for the future. I have had the opportunity in my previous role to gain experience in envisioning how we can help our clients and putting that into action.  I want to “capture lightning in the bottle” again.

What are some key challenges you anticipate facing in your new role and how do you plan to address them?

There are internal and external challenges. From an internal perspective, I have been with several firms. While there are common threads in consulting, each firm has their own focus and community culture. I need to take the time to learn about these and make sure that I do not undermine the culture and community that has made ProspHire successful. That means I need to listen more than talk… for those who know me, that is a tall order. Listening is also a key requirement to contributing to the refinement of the strategic vision.

Externally, re-engaging with client relationships, building new relationships and educating them on what ProspHire offers. I am anxious to contribute and be incremental to our success. Developing new relationships and maintaining those who already know me is something that I have had to do for some time so it is really understanding what we can offer today in addressing our client’s challenges and collaborate with clients to meet their needs and timelines.

Could you elaborate on your experience collaborating with health plans and state health agencies to streamline administrative processes and drive transformative initiatives?

One of the first opportunities that I had in getting involved with health care was my involvement with a US-based performance metrics study that examined and compared insurers performance across the entire process value chain, including costs, process, quality, technology and staffing. It gave me a solid foundation in understanding how top performing plans operate, as well as a keen understanding of how up- and down-stream processes impact each other.

I was also fortunate to get a great deal of insights in how state agencies and health plans worked and interacted with each other in the Medicaid space – both in the implementation of their core platforms but also in understanding how to communicate with the states and CMS.

On the Medicare book, it is about understanding the regulations and the impact to core clinical and administrative operations. A lot of that comes from just getting involved with those initiatives. This experience was tested when helping an insurer get its Medicare Advantage book of business out of CMS sanctions. Given the growth of Medicare and Medicaid, I am fortunate to have gotten involved in them early in my career.

What are your priorities in terms of expanding ProspHire’s client base and enhancing service offerings?

I am looking forward to learning more about our existing service offerings and solutions so that I can articulate to our current clients and future clients what we do exceptionally well. That is really the first order of business and everyone at ProspHire has been so good at educating me.

My initial thoughts on expansion are focusing on clients’ needs related to doing more with less while navigating the current uncertainties of the marketplace – economic, upcoming election, increased regulations and customer trust. This implies the need for strong core operations and administrative costs efficiencies across commercial, Medicare and Medicaid. Insurers need to take the opportunity to weather these challenges and come out well positioned to optimize expense management, technology to improve operation workflows and maintain quality and affordable care.

How do you build collaboration and innovation within the team to ensure continued success and growth?

I see my job as learning what is important to each of our team members to be successful and how they define success. It is going to be different for each of us. The trick becomes how do we align that with what is important to our client’s success. Sharing and collaborating on opportunities and taking the approach of pulling in the right set of team members to make the client successful will be key.

Can you provide insight into specific areas with healthcare consulting that you believe holds the most potential for growth and development in the coming years?

Medicare and Medicaid are lines of business that will continue to grow; it just so happens, processes and regulations will create the greatest needs because of the regulatory complexity. I do believe that ProspHire is positioned to help our clients meet those needs, along with supplemental benefits – the Firm has a very strong and growing dental operations solution.

We are also seeing growth potential for our “payvider” clients and believe that this segment will continue to grow and will have unique opportunities where we can support them.

What role do you see technology playing in shaping the future of healthcare consulting and how do you help to incorporate technology advancements into the firm’s strategies?

Technology serves as a driving force for innovation and transformation in navigating the complex healthcare landscape. We need to help our clients think through how to leverage technology tools and solutions that address today’s healthcare challenges.

In the near term, I see insurers focusing technology initiatives in the areas of improving workflow quality and timeliness in clinical and administrative operations, such as Appeals and Grievances, Provider Network data, Stars and Quality measures. These areas allow insurers to quickly address member and provider needs and regulatory changes.  And of course, we cannot talk about technology without mentioning how advanced analytics and Artificial Intelligence (AI) will impact healthcare. The value of AI will come in helping to identify clinical and administrative options. We still are learning how to use AI and what are the limits of its capabilities. My thinking is that healthcare should be using this technology in identifying potential options in care and claims management but human decision-making is still required in executing. 

I am excited to help think through how we incorporate technological advancements into our solutions and strategies that focus on how we help our clients transform.

How do you plan to uphold ProspHire’s commitment to providing unparalleled expertise and leadership to its clients and what measures will you take to ensure client satisfaction and success?

By listening to what our clients’ needs are and what it means to them personally and professionally. It is not enough that we help the client solve their challenges, but we want to help them to be successful too. We work in an industry where there is not much differentiation in what we do. Our clients need to know us as someone who they can call to help them solve a critical need.

Soaring to New Health – Season 2, Episode 2: SDOH in the Community

Written by LBodnarchuk on . Posted in Blog.

Welcome to Season Two of ProspHire’s Soaring to New Health podcast! In this episode, we delve into the critical impact of Social Determinants of Health (SDOH) on our communities, particularly focusing on housing and its implications for the well-being of children and families. Joining us today are two distinguished guests: Stephanie Meyer from the Pennsylvania Department of Human Services and Chris Watts, the CEO of the Boys and Girls Clubs of Western Pennsylvania.

Chris Watts shares insights into the Boys and Girls Clubs’ mission, serving over 7,500 kids annually in Western Pennsylvania. Their programs focus on providing safe environments, academic support, character development, healthy lifestyles and career readiness to help children reach their full potential.

Stephanie Meyer highlights the role of the Pennsylvania Department of Human Services in supporting over 3 million Pennsylvanians through various programs, including Medicaid, nutrition assistance and housing initiatives. The department’s focus on addressing housing instability and providing critical resources during the pandemic reflects their commitment to a thriving Pennsylvania for all.

Tackling Barriers: The conversation shifts to addressing housing barriers, with Stephanie discussing initiatives like the Emergency Rental Assistance Program and efforts to increase access to affordable housing. Chris Watts emphasizes the Boys and Girls Clubs’ commitment to reducing barriers for families, including transportation and paperwork processes, to ensure all children have access to quality programs.

The Impact of Social Determinants: Both Stephanie and Chris emphasize the tangible impact of Social Determinants of Health, such as homelessness and housing instability, on children and families. They paint a vivid picture of the challenges faced by those experiencing housing insecurity and underscore the need for collaborative efforts to address these disparities.

Investing in Quality and Access: Both community leaders highlight the importance of investing in quality childcare and early learning programs. Stephanie praises the Boys and Girls Clubs’ commitment to quality, as evidenced by their high accreditation rating, while Chris emphasizes the need to ensure access to high-quality programs for all children, regardless of their circumstances.

It’s evident that addressing Social Determinants of Health requires a multifaceted approach involving government agencies, community organizations and stakeholders. By working together and investing in quality programs and resources, we can create a healthier and more equitable future for our communities. To learn more about how you can get involved, listen to the entire episode here: Listen to the Soaring to New Health Series | ProspHire

The Spotlight is Back on HEDIS for Stars

Written by LBodnarchuk on . Posted in Insights.

This is the time of year where all health plans are focusing on two Star Years (SY) at once. It is important that SY2025 is closed out strong, while simultaneously building the right strategy for SY2026. As we are already over three months into SY2026, the time is now to start focusing on execution of your targeted interventions to support improvement within Stars specifically within The Healthcare Effectiveness Data and Information Set (HEDIS©). In previous years, the spotlight was on Member Experience driving most of the weighting but in SY2026 it will decrease to a 2x weight (previously 4x weight) making other domains such as HEDIS essential to drive performance.

SY2025 Closeout

The beginning of the calendar year means it is HEDIS/Medical Record Review season and within this timeframe; everyday matters, so make them count. With approximately a month left, health plans need to leverage their strategic provider partnerships and utilize data reporting and tracking to optimize opportunities for quality improvement (QI) and ultimately achieve their year-end Stars’ goal.

Leveraging provider partnerships: Now is the time to lean in on your plans’ relationship with providers who care for your members. Utilizing your previously developed provider repository, accessing provider group Electronic Medical Records (EMRs), and knowing when to escalate in areas needing additional support is key.

Data reporting and tracking: Real-time data updates regarding chart chase status, measure-level gap analysis/forecasting and identifying key opportunities for broad chart closure efforts are critical to ensuring a successful close-out to Hybrid season.

SY2026 Strategic Plan and Execution

As we enter a new Stars Year, it is critical that your plan is poised for success by setting clear and achievable goals. This year presents the opportunity to innovate and refine your plan’s approach, particularly with new interventions targeting both identified priorities and newly introduced measures. As we navigate the ever-evolving Stars landscape, it is key to maintain alignment across all areas of the organization to effectively adapt to industry changes and emerging trends. By fostering collaboration and strategic alignment, your plan can maximize its potential, achieve the goals set forward and make a meaningful impact on the health of your members.

Ensure your goals are set: Conduct goal setting activities to achieve your contract-level goals and establish priority measures that will have significant impact on your plans performance if the goals are achieved.

Develop new interventions for priority measures: Plans must look ahead and continue to be innovative with interventions, relying on what got you here will not get you to where you want. Develop key strategies around the priority measures to ensure continuous improvement is driven forward.

Alignment across the organization of industry changes for SY2026: Plans must understand how the industry is changing every year in Stars. With the weighting shifting away from member experience, success in HEDIS will be more necessary to drive a plan’s performance. Key changes for this SY are outlined below:

  • Addition of Kidney Health for Patients with Diabetes (1x weight)
    • Colorectal Cancer Screening removed from Hybrid Reporting – moved to Electronic Clinical Data Systems (ECDS)
    • Introduction of Health Equity Index – monitoring applicable HEDIS measures for Social Risk Factors

At ProspHire, we continue to partner with health plans, to offer insights, analysis and execution strategies to improve Star ratings. Do you need support developing the right SY2026 execution strategy? Let’s have a conversation.

*NOTE: HEDIS© is a set of standardized performance measures developed by the National Committee for Quality Assurance (NCQA).

Analyzing ACA Marketplace: Impact of Risk Adjustment Operations on ACA Marketplace Penetration and Growth

Written by LBodnarchuk on . Posted in Insights.

The Affordable Care Act (ACA) revolutionized healthcare in the United States by prohibiting insurers from denying coverage or charging higher premiums based on pre-existing conditions, leading to an increase in health insurance coverage amongst United States residents. A key process that was introduced with the creation of State ACA Marketplaces was the implementation of a Risk Adjustment transfer payment model. Each year, Department of Health and Human Services (HHS) completes a risk adjustment calculation which redistributes a percentage of premium revenue from ACA insurers with lower risk scores to ACA insurers with higher risk scores within their respective state markets. Failure to capture an accurate and complete risk score exposes an ACA insurer to the risk of understating the health risk of the population. Understating member health risk will lead to redistributing premium revenue needed for member care, causing an operational budget shortfall. A large value fund transfer may indicate a Health Information Oversight System (HIOS) contract was unable to capture an accurate and complete risk score for its population and signal financial headwinds entering the next benefit year.

ACA enrollment continues to grow as seen by the surge in 2024 numbers increasing to 21.3 million people, up from 16.4 million people in 2023 (Jared Ortaliza, 2024). The recent increase in enrollment signals a potential increase in ACA Marketplace insurers. Insurer participation in the ACA Marketplace has been variable since the start in 2014. (McDermott & Cox, 2020) The highest level of participation was in 2015, at an average of 6 insurers per state (ranging from 1 insurer in West Virginia and New Hampshire to 16 insurers in New York). Insurer participation declined after 2015 to 4.3 insurers per state in 2018 with the change being attributed to insurance company losses. The process of launching a product is complex from the initial application and benefit design through to operations. Insurers entering the market may face financial headwinds within the first few years unless the appropriate strategies and operations are deployed. Risk adjustment might contribute to financial headwinds if not appropriately planned and executed during the preparation and operations of the first year.

ACA Marketplace participation has been increasing since 2018, reaching 5 insurers per state in 2021. As the market approaches the high-water mark set in 2015, one might wonder if a market contraction is coming. ProspHire was interested to understand if risk adjustment outcomes are a contributor to new HIOS contract financial performance. ProspHire conducted a simple analysis by comparing the HHS Summary Report on Permanent Risk Adjustment Transfers for the 2022 and 2021 benefit years to answer two questions:

  • Was there an increase in new HIOS contracts and new insurers from 2021 to 2022?
  • How did the new HIOS contracts and new insurers fare in their first year of operations?

In 2022, there were 346 non-catastrophic individual ACA Market HIOS contracts compared to 294 in 2021, indicating a net growth of 17% (346/294). Of the 346 plans, 39 were new HIOS contracts in 2022 of which 11 were HIOS contracts given to new insurers (Table 1). New HIOS contracts were more likely to have a risk adjustment transfer payment to the state. Of new HIOS contracts, 82% (9/11) of new insurers and 89% (25/28) of existing insurers completed transfer payments to the stat compared to the national market rate of 57% (197/346).

Table 1: Frequency of Transfer Payments to the State in 2022 by New versus Existing Status

This simple analysis indicates new HIOS contracts entering the ACA Marketplace are more vulnerable than the existing HIOS contracts to completing transfer payments back to the state at the end of the year for risk adjustment. Past history as an ACA insurer does not seem sufficient to avoid a yearend transfer payment to the state. This analysis indicated that new and existing insurers with new HIOS contracts had similar likelihood for risk adjustment transfer payments. Insurers preparing to enter the ACA Marketplace with a new HIOS contract should consider two items. First, the revenue return is a cash transfer from the ACA insurer to the state and it cannot be avoided, even if the ACA insurer elects not to participate in the subsequent year. Second, many operational pieces must be implemented in quick succession to improve the opportunities to capture an accurate and complete risk score in the first year of operations:

  • Prospective programs to increase provider and member engagement in completion of comprehensive examinations.
  • Encounter submission platform implementation and calibration with a corresponding error correction management workflow.
  • Retrospective program chart retrieval targeting, chart retrieval vendor selection and implementation, and a highly accurate chart review vendor.
  • Risk Adjustment Diagnosis Validation (HHS-RADV) vendor selection and management process.

Whether an Insurer is already established in the ACA Marketplace, or looking to join for the first time, a thoughtful risk adjustment strategy is just one piece of the puzzle to ensure success. ProspHire is uniquely positioned to support your organization through the QHP application process, operational readiness, vendor implementation and strategy advisory. Connect with us to learn more.

Former EY Healthcare Leader Joins ProspHire as Managing Director

Written by LBodnarchuk on . Posted in News.

ProspHire, a prominent national healthcare consulting firm, announces the appointment of Tim Calhoun as Managing Director. With his extensive experience in healthcare consulting, Tim will be driving senior-level executive and client relationships, focusing on client retention and growth and identifying new opportunities.

Tim joins ProspHire from Ernst & Young (EY), where he held a pivotal role in serving commercial, nonprofit and governmental healthcare clients. With more than two decades of experience in consulting services, Tim brings a wealth of knowledge, particularly in healthcare, with more than 15 years dedicated to this dynamic industry. His track record includes collaborating with health plans and state health agencies to streamline administrative processes, enhance operational efficiency and drive transformative business and system initiatives.

Lauren Miladinovich, CEO, Managing Principal and Co-founder of ProspHire, expressed her enthusiasm about Tim’s appointment stating, “Tim is a compelling addition to our executive leadership team at ProspHire and will bring strong focus on further evolving our consulting practice to help our clients provide better access to healthcare.”

Tim’s appointment reflects ProspHire’s commitment to providing unparalleled expertise and leadership to its clients, further solidifying its position as a leader in the healthcare consulting domain.

Dental Practice Management – Steps to Transform a Standard of Practice Playbook

Written by LBodnarchuk on . Posted in Insights.

The standardization and alignment of administrative and clinical processes to current state best practices and technological advances is a core but often overlooked part of dental practice management. Your practice management standards of practice involve the processes, resources and management strategies involved in driving your daily workflows and patient care. This includes everything from patient and insurance data management to your financial reporting and resource allocation. The management of a dental practice may look different for a privately owned practice or practice group versus a dental service organization. Ultimately, no matter the type of operational model of your organization, it helps you run efficiently, stay compliant and maintain above average patient satisfaction on a consistent basis.

Every dental practice needs careful organization to run smoothly. You can deliver the dental experience your patients and team deserve with a streamlined approach to dental practice management — starting by updating your standards of practice playbook. This document covers compliance, employee training, dental procedures, reporting recommendations and more. Refreshing it will help you deliver a higher quality of care while making everything at your practice as straightforward as possible.

Your Dental Practice’s Standards of Practice Playbook

A practice’s SOP playbook is your guiding document. It sets up everything in your practice — how to handle treatment plans, patient intake and more. A SOP sets a high bar for care at your operation and keeps a consistent quality standard. While your SOP is essential for streamlining care and maximizing efficiency, it can become outdated. Neglecting to keep up with your SOP playbook can leave you with outdated, inefficient standards that decrease your service quality.

How to Upgrade Your SOP Playbook

Your SOP may be responsible for a dip in customer satisfaction or practice efficiency. Taking time to revamp your playbook is an excellent way to cut inefficiencies and improve your practice. Use these steps to bring your playbook into the present, ensuring your staff and customers get top-notch oral care.

1. Review Your Current Document

First, look at your current document. Carefully review every section, looking for improvement areas, inconsistencies, unclear procedures or outdated information. You can ask one or two employees to help you with this task. Your team members are an invaluable resource — they work with the playbook every day and may give you a fresh perspective you haven’t considered.

Reassessing your existing document gives you a better idea of what needs work, simplifying the rest of the process.

2. Define Your Objectives

Next, it’s time to define your objectives. What specific goals do you want to achieve with this update? What experience do you want to deliver?  Whether you’re looking to enhance patient safety, streamline administrative processes or ensure compliance with the latest privacy and industry standards, realistically achievable goals will help you pinpoint where to look for assistance and let you anticipate whether the ultimate outcome meets your needs. Plus, you’re less likely to forget something critical if you set goals upfront.

3. Gather Input

Since your staff deals with patients and procedures daily, talking to them is critical. Encourage open communication from your team during and after updating your document. Their experience-based feedback can make your playbook as valuable as possible. Additionally, reach out to customers or read their reviews. You might find a common complaint you can resolve with simple tweaks and improvements. A playbook that accurately reflects your team and customer experience will be more practical for daily use.

4. Research Applicable Regulations and Guidelines

Make sure your playbook is up to date on the latest changes in safety protocols, dental practices and other compliance requirements. You want your playbook to be as accurate as possible — failing to stay current with legal requirements can put you at risk for compliance-related issues and mean your dental care may be out-of-date with current clinical guidelines.

5. Simplify Language and Structure

Your playbook should be unambiguous and easy to read for maximum usefulness. Use simple language throughout to prevent misunderstandings. Additionally, consider visual aids, illustrations and flowcharts for improved accessibility. These tools make your playbook more reader-friendly, usable and memorable.

6. Include Comprehensive Information

A thorough SOP playbook covers everything your practice might need to deal with. Include employee training, dental procedures, privacy requirements, ethics standards, infection control protocols and more. Everything your dental practice offers and promises should be up to date and accurate. A playbook that mentions every detail is more relevant for your team.

7. Customize Your Practice

Someone else’s playbook can be a good reference point, but no practice is identical to yours. Read your document to ensure it covers your team’s specific specialties, needs and workflows. Remember, a more effective playbook equals a more effective dental service.

8. Get Feedback

Once you’ve completed the new playbook, ask for more team feedback. Encourage employees to take notes on the update and how well it works with their day-to-day needs. Did you mention something that’s impractical in real life? What processes are more efficient thanks to the update? Emphasizing collaboration lets you use your team’s strengths to create the best possible document.

9. Regularly Update and Review

Your playbook should be a living, evolving document — never set in stone. Letting it stagnate allows it to become outdated and inaccurate. You should establish a review schedule to help you address any emerging issues, add new industry best practices and adapt to technological advancements. A dynamic playbook reflects your commitment to quality in customer service and dental practice.

10. Use a Management Partner

While good dental practice management starts with your playbook, investing in a partnership can take your practice to the next level. Working with a dental practice management service lets you streamline your operations through automation, reducing errors and improving efficiency. It also enables employees to leave feedback on training sections and allows you to standardize your operation further. When paired with your playbook, a partnership delivers a better experience for your employees and customers.

Why ProspHire?

Choose ProspHire for industry-leading innovation that optimizes your dental practice management. We understand and meet healthcare consulting’s evolving needs. Our team’s dedication to service has earned us spots on the Inc. 5000 and Pittsburgh Business Times‘ Fastest-Growing Companies list.

We specialize in addressing the challenges dental service organizations and dental providers face. ProspHire offers cutting-edge solutions for PMS implementation, SOP playbook transformation, workflow redesign and more. Contact us online to learn more about how we can help you.

References:

https://www.cdc.gov/phlp/publications/topic/hipaa.html

https://www.ada.org/en/resources/research/science-and-research-institute/evidence-based-dental-research

https://www.prosphire.com/blog/what-is-dental-practice-management/

https://www.prosphire.com/services/dental-practice-management/

Q&A with ProspHire’s Julie Evans on Medicaid

Written by LBodnarchuk on . Posted in Insights.

The Medicaid population is one of healthcare’s most vulnerable populations requiring unique, frequent and customized delivery of care to provide the resources and services necessary to address health disparities. This leads to significant challenges for care providers in navigating the continuously evolving and regionally unique Medicaid environment. With escalating pressure to contain costs, adapt to Medicaid expansion, address health equity and social risk factors and improve quality performance, the call for effective strategies has never been more pressing.

At ProspHire, our team of Medicaid specialists and project executors offers innovative solutions tailored to the needs of federal and state healthcare agencies, Medicaid health insurers, health systems and pharmacy benefit managers. In this Q&A session, we engage with our Medicaid Practice Leader Julie Evans to dive into various topics spanning delivery, implementation, operations, organization, strategy and technology, offering insights and expertise to address the complexities of the Medicaid landscape.

Can you provide an overview of ProspHire’s approach to how you help clients drive innovation and sustainable improvement in Medicaid?

One of ProspHire’s core values is relationships. As we seek to drive innovation and sustainable improvement in Medicaid, our first step is to understand each health plan’s unique population and regional priorities through relationships with Medicaid beneficiaries, customer facing teams and community-based providers.

State regulations and region-specific needs are the foundation of Medicaid services and pose unique guardrails for our clients. While state regulations are rigid and defined, region-specific needs vary and evolve leaving room for innovation. Through a customer-centered approach, we seek to understand, rather than assume, and drive innovations that are inspired by the customer, leading to desirable and sustainable improvement.

ProspHire partners with our clients to amplify the voice of the customer through the ideation and execution of their innovations by means of strategic initiatives in alignment with organizational priorities.

What are some of the most pressing challenges that healthcare organizations face in navigating Medicaid landscape, particularly considering recent regulatory changes?

The Covid-19 pandemic started 4 years ago, yet today we continue to see the continuous impact on the Medicaid population and landscape. The pandemic inspired an increased focus on health equity, as those affected by Social Determinants of Health, such as the Medicaid population, saw a compounded impact of the pandemic on health outcomes. Healthcare organizations have faced several challenges in appropriately addressing individual needs within the confines of their services and finances given the vast number of challenges impacting health outcomes.

Since the pandemic, we have seen a shift in policy expanding Medicaid coverage and access to care through Section 1115 waivers. Through the current administration, states are permitted to propose Section 1115 waivers focused on new approaches to reduce health disparities and expand coverage and benefits. As a Small Diverse Business (SDB) in Pennsylvania working alongside several of the state’s Medicaid Managed Care Organizations, we have had a particular interest in the pending Pennsylvania Keystones of Health submission.

The approval of the Pennsylvania Keystones of Health waiver focuses on the Social Determinants of Health to improve the health of Pennsylvanians through new and innovative programs. Ultimately, these provisions will funnel additional opportunities and implementation challenges through Managed Care Organizations whose beneficiaries will greatly benefit in the long-term.

How does ProspHire stay on top of the evolving Medicaid regulations and policies and how do you ensure your clients remain compliant?

Read, watch, listen and react. Like many of our clients, we stay up to date on the industry changes, trends and discussions to prepare ourselves and others to react to our evolving environment. This includes the ever-changing needs and priorities of the unique populations that make up a plan’s membership and there is no one who knows their membership better than our clients. Although it isn’t always the most fun activity, our attention to detail and quality assurance practices help us work in partnership with our clients and their legal and compliance teams to drive results.

Can you share a success story or case study where ProspHire’s Medicaid consulting services have significantly benefitted healthcare organizations?

It’s hard to choose just one… so I’ll have to give two. One is tied to a state-wide initiative in Pennsylvania focused on addressing health equity through a collaborative bringing together health systems, managed care organizations, community-based partners and other care providers. Our team facilitated the efforts to address health equity through regional population health assessments and intervention planning across stakeholder groups. This led to regional playbook development that was eventually adopted by the Department of Health for future state implementation. The opportunity to collaborate across healthcare organizations, build meaningful partnerships and drive patient-centered change was of benefit to those engaged in the collaborative and the communities to be impacted.

The second is an engagement that has been in existence almost as long as ProspHire, where we are partnered with a Medicaid Managed Care Organization’s quality team to provide project management services. By offering project management support, our team can support the planning, design and implementation of Medicaid Quality initiatives year-over-year, continuously collaborating with the client to drive improved health plan performance.

Medicaid expansion has brought significant changes in the healthcare industry. How does ProspHire assist clients with adapting to these changes and leveraging opportunities for growth?

Medicaid expansion, in addition to Medicaid unwinding, has led to a series of fluctuations in Medicaid membership. Since 2014, the Affordable Care Act opened the door to Medicaid expansion and many but not all states have taken the opportunity to do so. During the pandemic, continuous enrollment protections were put in place to maintain enrollment of and protect health coverage for almost all Medicaid enrollees. In April 2023, this condition was lifted, reverting states back to business as usual and causing all Medicaid enrollees to be reevaluated for eligibility.

Through these changes, ProspHire supports health plans prepare for scalability or sustainability through operations, improve member transition from Medicaid to marketplace or vice versa with a focus on continuity of care and continuously evaluate operating model and administrative costs as required.

For plans that are looking to enter the Medicaid market within a state or increase Medicaid enrollment through growth strategies, our team is equipped and prepared to support health plan expansion into new lines of business or regions. From operationalization to delivery, our industry knowledge and experience position us to support across all government programs.

Technology plays a crucial role in modernizing healthcare delivery. How does ProspHire integrate technology solutions into its Medicaid services to improve efficiency and outcomes?

Technology is continuously increasing in significance across healthcare delivery. Most recently, our team supported the integration of a new clinical platform to enhance care management, utilization management and reporting capabilities. From requirements gathering to go-live and post go-live risk management and resolutions, our team has been in the weeds, working alongside the client to deliver a multi-state clinical solution. This tool improves efficiency of workflows, decision making and ultimately the delivery of care to the Medicaid population and those who are most vulnerable to adverse health outcomes.

Plans have different technological needs depending on the current state of their operations and we partner with our clients to integrate the solutions that are prioritized in alignment with organizational goals to deliver improved member outcomes.

Can you talk about the importance of data analytics in Medicaid projects and how you use data-driven insights to inform decision-making and strategy development?

Social Determinants of Health (SDOH) and health equity are buzz-worthy terms that have led to a shift in the way specific care needs are identified and delivered. A challenge posed by SDOH and ultimately health equity, is the variation in need based on environmental factors. Through partnerships with community-based organizations and our clients, mutual goals can be achieved by addressing social needs and downstream health outcomes.

To do so, data analytics is crucial. Who is our population of focus? Where do they live? What impact will our intervention have? These are all questions that data can provide insight to. Knowing this, ProspHire has supported population health assessments and data dashboards focused on marrying publicly available data and internal clinical data to support data-driven decision making. These tools support strategic development and inform the who, what and where of many Medicaid projects, specifically those focused on quality.

With the rise of value-based care models, how do you assist clients in transitioning from fee-for-service to value-based reimbursement structures within the Medicaid space?

Pay for performance models, shared savings programs, patient centered medical homes, Medicaid ACOs… the many value-based care models, continue to evolve and demonstrate their effectiveness. Our focus is to support the readiness and feasibility of transition followed by the monitoring and controlling of care model commitments. The continuous need to reduce costs and deliver improved quality of care poses a challenge to both providers and payors and leads to the continuous need to reevaluate and refine our reimbursement structures.

Looking ahead, what trends do you anticipate shaping the future of Medicaid consulting and how is ProspHire positioned to address these trends proactively?

Although predictable to say, quality improvement and cost reduction are and will continue to be a focus in Medicaid. I anticipate that these competing priorities will continue to be an area of focus, but rather than feeling miles apart, will slowly feel more symbiotic.

Let’s use maternal morbidity and mortality as an example. The cost of maternal morbidity and mortality in the U.S. is tens of billions of dollars a year. The cost savings that would come from quality improvement are substantial and in the developed or industrialized world, we have the highest maternal mortality rate that continues to increase and inequitably impact black women. A priority such as this seems unquestionable.

 As we continue to look at high-cost low-quality outcomes, we begin to see the vast opportunity for all. Our hope is to continuously be aware of and prepared to address these areas of need, evaluate trends, think innovatively and strategically and ultimately drive change for our clients and the Medicaid population.

Doctors looking at laptop

What is MLTSS and Why is it Important?

Written by LBodnarchuk on . Posted in Insights.

What is MLTSS?

Long Term Services and Supports (LTSS) include a variety of care activities focused in medical and personal care including activities of daily living (ADL) and instrumental activities of daily living (IADL). Managed Long Term Services and Supports (MLTSS) is the delivery of LTSS through capitated Medicaid Managed Care programs.​

Under the responsibility of Managed Care Organizations (MCO), MLTSS moves away from the Medicaid fee-for-service model that continues to exist today. States may leverage one or both systems to deliver LTSS to beneficiaries. Over time, states have been increasingly adopting the MLTSS model alongside the increase of home- and community-based services (HCBS). LTSS has continuously shifted toward HCBS, with the support of legislature, allowing health services to be delivered outside of the institutional care setting and reducing costs of care. Through MLTSS, states are able to encourage an increase in HCBS and predict budget while incentivizing MCOs for improved care coordination.​

As states continuously initiate, enhance and expand their MLTSS programs to accommodate the evolving care model and permissions, MCOs will be challenged to think strategically and innovatively to offer tailored person-centered services plans that accommodate the home-and community-based care model.​

Why is MLTSS Important?

The growth of the aging population in the U.S. is unseen in U.S. history. Projections estimate a 26% increase in the number of Americans ages 65 and older over the next 20 years, equaling approximately 17 million people1.  As our population ages, and lives longer through medical and technical advances, there is an increasing need to improve the LTSS care model with a focus on HCBS. Through HCBS, beneficiaries can continue life at home and in the community while receiving necessary care without the need for an increase in institutional care facilities. MLTSS creates an environment for specialized care coordination and services to meet the needs of our growing elderly population.​

Managed Care Organizations are being tasked by states to operate long term services and support under a capitated payment model, leading plans to think strategically to position themselves for optimal margins and performance.​

As a consultancy 100% focused on healthcare, ProspHire is equipped to support MCOs navigate the MLTSS model through gap analysis, plan design, operational readiness, program optimization and innovation. Our industry experience and commitment to serving the community provides a unique perspective and patient-centered approach. Whether your plan is looking to enter the MLTSS market, improve performance or execute a large-scale strategic initiative, our team is equipped and committed to work in partnership with our clients and drive results.

Understanding the Risks of Healthcare System Disruptions

Written by LBodnarchuk on . Posted in Insights.

In the world of healthcare, so many things are interconnected – between technology systems, platforms and other business operational functions. If errors, shutdowns or broad sweeping external factors disrupt operations, the impacts can be far reaching and significant to members and providers.

What are some of the ways that systems, technology and platform disruption can have on the healthcare ecosystem?

Health Insurers:

  • Operational Disruptions: Delays in claims processing and increased manual workloads can lead to operational inefficiencies and higher administrative costs.
  • Financial Impact: Increased claims processing times and potential for fraud during disruption could lead to financial losses.
  • Regulatory Compliance Risks: Difficulty in meeting regulatory reporting requirements and compliance deadlines could result in penalties and reputational damage.
  • Member Satisfaction: Delays in claims processing and potential confusion about coverage could lead to decreased member satisfaction and trust.

Health Plan Beneficiaries:

  • Access to Care: Delays in prior authorization and claims processing may temporarily limit access to necessary medical services or medications.
  • Financial Burden: Beneficiaries might face higher out-of-pocket costs or delays in reimbursement for healthcare services.
  • Confusion and Anxiety: Lack of clear information and potential disruptions in service could lead to confusion and anxiety among patients regarding their care continuity and coverage.

Providers:

  • Revenue Cycle Management: Delays in claims submissions and reimbursements can strain financial liquidity and impact the overall financial health of healthcare providers.
  • Administrative Burden: Increased administrative work to manage manual claims processing and communications with health insurers can divert resources from patient care.
  • Patient Care Impact: Potential delays in receiving payments may affect the ability of providers to offer timely and comprehensive care, especially for smaller practices with limited financial reserves.

Pharmacies:

  • Prescription Processing Delays: Disruptions in electronic prescription services and insurance verification processes can lead to delays in dispensing medications to patients.
  • Financial Impact: Cash flow issues may arise from delays in reimbursement from insurers, affecting the operational stability of pharmacies.
  • Customer Service Challenges: Pharmacies may face increased pressure from customers experiencing delays or issues with medication access, impacting customer satisfaction and loyalty.

Downstream Entities (e.g., labs, medical device companies):

  • Operational Disruptions: Entities reliant on timely data exchange and payment processes may experience operational delays and inefficiencies.
  • Supply Chain Impact: Disruptions in payment and ordering processes could affect the supply chain, leading to delays in delivering medical supplies and devices.
  • Financial Strain: Delays in payments for services or products could impact on the financial stability of these entities, particularly those with tight operating margins.

If your plan is ever impacted by these types of disruptions, ProspHire is equipped to support you. Our deep expertise in strategy, operations and technology within the healthcare sector positions us perfectly to assist health plans in navigating the complexities. Here are several ways we could provide valuable assistance:

Strategic Response and Recovery Planning

Rapid Impact Analysis:

  • Our team of payor experts and delivery consultants can quickly produce an impact analysis with plans for developing or executing your existing downtime procedures. We’ll aim to establish governance and track business needs until normal operations proceed.
    • Identify services of most impact (Prior Authorizations, Claims, etc.)
    • Rapidly develop, review and execute business continuity procedures.
    • Establish governance processes and tracking to minimize operational impacts.
    • Establish transition procedures to return to normal operations.

Incident Response Strategy:

  • Help develop or refine an incident response plan tailored to cyberattack scenarios, ensuring quick and effective action to minimize damage. Enhanced with agile capabilities and processes to continually prioritize pain points.

Business Continuity Planning:

Assist in creating or updating business continuity plans that specifically address cyber threats, ensuring that critical operations can continue with minimal disruption.

  • Compliance and Risk Management: Guide health plans through the complex landscape of healthcare regulations (such as HIPAA) related to cybersecurity, helping them to meet compliance requirements and manage risks effectively.
  • Technology Implementation Support: Advise on the selection and implementation of advanced cybersecurity technologies and practices, including encryption, multi-factor authentication and network segmentation.
  • Process Optimization: Review and optimize operational processes to enhance efficiency and resilience, ensuring that manual processes are in place to maintain operations during digital system outage and robust planning to ensure a swift return to operational effectiveness.
  • Communication Planning: Help develop communication plans that clearly outline how to communicate with internal and external stakeholders during and after a cyberattack.

If you or your health plan leadership needs support to navigate technological or system disruption, connect with us today.

ProspHire Diversity, Equity and Inclusion Transparency Report

Written by LBodnarchuk on . Posted in News.

Together, We Prosper.

The release of ProspHire’s first Diversity, Equity and Inclusion Transparency Report marks a critical milestone in our continuous commitment of fulfilling our core purpose of helping people prosper. This report provides transparency into our DEI initiatives, workforce composition, recruitment and retention efforts and areas of external engagement. We are holding ourselves accountable to taking the steps we know are essential to continue to strengthen our culture, empower our people and drive positive change.

To learn more about our Diversity, Equity and Inclusion journey, download our report here

Accountability Starts at the Top​

At ProspHire, we firmly believe that initiatives and action on DEI require unwavering support from executive leadership. We leverage firm wide programs to create platforms for intimate dialogues and individual avenues for personal development, which allow for an ongoing evolution of our DEI approach to address the ever-changing conversations essential to all the facets of diversity within our organization.

​​“We understand that organizations enriched by diverse voices and perspectives are better positioned for success. They build quicker innovation, make smarter risk assessments, exhibit deeper resilience and are better equipped to turn challenges into opportunities. We have seen the advantages of advancing DEI within our operations and therefore, we remain committed to continually prioritizing DEI at every level of our firm.”

Lauren Miladinovich​
CEO, Managing Principal and Co-Founder​