PITTSBURGH, PA – ProspHire announced today that it has been named #3337 on Inc. Magazine’s annual list of America’s Fastest-Growing Private Companies – the Inc. 5000. The rank reveal also put ProspHire at #14 in Pittsburgh, #84 in Pennsylvania and #330 in the nation for business products and services. The list represents a unique look at the most successful companies within the U.S. economy’s most dynamic segment – independent, small businesses. ProspHire, a national healthcare consulting firm, is recognized for its revenue growth.
“We are honored to be included on this prestigious list of the nation’s fastest-growing private companies for a third consecutive year,” said Lauren Miladinovich, Managing Principal and CEO of ProspHire. “This demonstrates our continued commitment to excellence as we navigate some of the toughest challenges our firm has ever faced. Our team remains focused on bringing deep healthcare industry knowledge and exceptional service to every client.”
The companies on the 2022 Inc. 5000 have not only been successful but also demonstrated resilience amid supply chain issues, the labor shortage and ongoing impact of COVID-19.
Chris Miladinovich, ProspHire’s Principal and COO, said, “The last few years have been volatile for small businesses like our Firm, so to be recognized 3 years in a row as an Inc. 5000 Fastest Growing Company is an absolute honor. We’ve had double digit growth year over year since our founding, which is a direct result of the amazing work of our employees and the partnerships with our clients. It proves our model for growth is thriving even through unprecedented economic times.”
“The accomplishment of building one of the fastest-growing companies in the U.S. cannot be overstated,” says Dan Crogan, Principal and SVP of Consulting. “It validates ProspHire’s leadership team and our employees who work tirelessly on behalf of our clients. Our success and continued growth in this highly competitive and demanding healthcare industry is a testament to that hard work and to our wonderful clients with whom we’ve been able to Prosper Together over the years.”
Complete results of the Inc, 5000, including company profiles and an interactive database that can be sorted by industry, region, and other criteria can be found at www.inc.com/inc5000.
About ProspHire
ProspHire is a national management consulting firm focused on healthcare advisory, project delivery and strategic sourcing. Founded on the core value of relationships, with the goal to “prosper together”, ProspHire partners with clients to identify and solve their most significant people, process and technology challenges. The women-owned and rapidly growing Pittsburgh-based firm has nearly a 100 dedicated practitioners and consultants who deliver on projects and services across the U.S.
As any healthcare executive knows, running a healthcare organization is complex and fast-paced, with many moving parts and minimal margin for error. A robust project resource management system is essential to respond to this tension well.
Hospitals and healthcare organizations provide essential services in any society, keeping us healthy, helping us live our lives well and providing care when we need it most. Learn more about the importance of project resource management for this essential service below.
What Is Project Resource Management?
Project resource management helps organizations control costs, reduce risks and improve outcomes. In the late 1960s, when project management emerged through a non-profit organization called the Project Management Institute (PMI), its initial goal was to:
Advance careers
Strengthen organizational success
Teach project management professionals new skills and enable them to maximize their impact
Even as new technologies have caused project management to grow exponentially, those goals remain relevant today.
Strong project management involves several individuals working to streamline workflow. Significant positions within project management include:
Project managers: A project manager helps plan, organize and oversee the daily workflow of a particular team. Their guidance advances specific projects so the organization can achieve its goals in efficient ways.
Project sponsors: A project sponsor initiates the project and defines the desired outcomes. Sponsors also liaison with stakeholders and provide resources so the project team can fulfill their role.
Project teams: The project team involves any individuals who carry out work related to the project. These individuals include the project manager, sponsor and any non-management workers involved.
Project stakeholders: Any person that the project impacts is a project stakeholder. Stakeholders can include investors, customers, patients, employees or other organizations.
How Does Project Management Work?
The four phases of traditional project management are:
Project initiation: When a project begins, the project sponsors review background information, market research and other pertinent data. After defining and aligning goals with organizational aims, the sponsors send the goals to relevant stakeholders for approval. Once the sponsors receive approval, they select a project manager to develop a project team and vision for execution.
Project planning: The project manager reviews the project goals that the sponsor has highlighted and develops a step-by-step execution plan. This plan outlines the budget, project-related activities and all individuals necessary to carry it out.
Project execution: While the project team carries out the activities, the project manager measures progress. The manager also monitors any significant deviations from the plan and responds appropriately.
Project closure: The project manager and sponsor review the results and report them to relevant stakeholders and team members. If necessary, they create an updated budget and timeline to compare to the original project scope.
Depending on the method used, a project management team may reorder or add to these phases to achieve the desired outcome. At ProspHire, our approach to project management is:
Project initiation: We align our approach with the business case and organizational benefits.
Project planning: We define the scope and project management strategy.
Project execution: We develop cadence with leadership and deliver the product.
Our outcomes include an improved speed to market, better communication models, stakeholder alignment and increased productivity. For example, we helped a managed care organization complete a large-scale software migration. Our oversight and expertise helped the client complete the project on time while staying within their scope and budget. As a result, they received a 2-3x return on investment.
How Is Project Management Beneficial for Healthcare?
While project resource management is beneficial for every industry, some of project management’s benefits for your hospital or healthcare organization include:
Enhancing patient care quality by streamlining processes involved in providing patient care.
Increasing productivity and sharpening communication among healthcare staff.
Strengthening organizational planning and refining budgeting to align resources with high-priority work.
Augmenting processes designed to decrease lawsuit risks through improved quality of patient care.
Improving relations with stakeholders such as insurance companies, clinicians, patients, caregivers or government agencies.
Importance of Resource Management in Healthcare
Healthcare is one of the U.S.’s largest growing industries and foundational to any well-functioning society. Effective resource management can prepare healthcare organizations for crises and help all patients receive adequate care.
As the U.S. population ages and more Americans obtain health insurance, the need for efficient and effective healthcare delivery processes increases. Additionally, crises like the COVID-19 pandemic or an economic recession can lead to patients delaying or canceling procedures. With less income from elective procedures, hospitals can lose revenue and struggle to provide adequate care to all patients. A robust project management system can help healthcare workers meet these inevitable challenges with readiness and confident action.
Medical error accounts for over 22,000 deaths per year, often due to miscommunication, mismanaged data or faulty processes. An effective project resource management system can help reduce errors by putting sound processes in place, upgrading facilities and software and improving staff training for best practices.
Effective Resource Management Strategies
You can choose from several resource management methodologies and strategies depending on what works best for your organization and project. Some standard resource management methods include:
Waterfall method: One of the most common project management methods, the waterfall method organizes projects in a sequential and linear pattern through several phases. Because the project team completes each stage before starting the next, the waterfall method offers fixed costs and predictability.
Agile method: Planning and execution co-occur in the agile method. Project teams collaborate with customers to break objectives into smaller tasks and rank them according to importance. The agile method is more versatile and adaptable than the waterfall method, allowing you to adjust your parameters and strategies as you go rather than following a linear path to reach your goals.
Hybrid method: The hybrid method combines the waterfall and agile approaches to bolster adaptability with effective planning. This method usually relies most on agile methodologies, incorporating waterfall methods at strategic phases.
Scrum method: Scrum is an agile methodology that organizes project tasks into “sprints” lasting one to four weeks. The Scrum master is the project manager, tasked with removing barriers and protecting the project team from outside forces that may impede progress. Regular team meetings to review the progress of each “sprint” are a defining feature of the scrum method.
Six Sigma method: While waterfall focuses on defined steps and agile emphasizes adaptability, Six Sigma is statistically driven. This method has a more hierarchical structure than other methodologies, prioritizing a standardized process by reducing defects and increasing the repeatability of optimal results.
The methodologies above are only a few examples of the many methods out there. Our project management professionals at ProspHire have extensive knowledge of each method. Our team understands the ideal circumstances for each one and the most effective strategies for implementing them.
Optimize Your Project Resource Management with ProspHire
If your healthcare company could use enhanced project management strategies, our professionals at ProspHire would love to speak with you! We are committed to delivering results that provide value to every sector of your organization so you can give the highest quality of care to your clients and patients. We welcome you to fill out our contact form below to get in touch with us and learn more about how we can optimize your project resource management.
Healthcare payers are constantly looking for ways to reduce or improve costs. One way to do that is to acquire another company in the healthcare industry or join with another payer.
If your organization is looking for ways to grow and improve, you might consider merging with or acquiring another. Learn more about the difference between mergers and acquisitions, the benefits of each and how to successfully navigate one or the other.
What Is an Acquisition in Healthcare?
During an acquisition, one healthcare organization gains control of another. For example, one insurer could acquire another to increase membership or enter a new market with enhanced products and services. Though larger companies typically buy up smaller ones, in some cases, one insurer might purchase another similarly sized one.
Following an acquisition, the purchasing organization takes over the operations of the practice it bought, often changing the hiring policies, operating hours and HR standards.
A healthcare payer might decide to purchase another payer or service provider for various reasons.
To start offering a new service: Acquiring a company that offers a service related to healthcare, such as a telehealth network, allows a payer to offer a new service to patients. If an insurer acquires a telehealth vendor, it can direct members to that vendor, reducing its healthcare costs.
To increase its member base: Acquiring another healthcare payer allows the first payer organization to expand the size of its member base. For example, if a larger insurer purchases another, it gets access to the acquired payer’s members.
To reduce costs: An acquisition can be a cost-cutting move, as well. An organization can purchase a company that produces specific types of medical equipment or offers certain services, reducing its expenses in that department.
To expand geographically: Acquiring another insurer allows a healthcare payer to increase its geographic footprint. For example, a New York-based insurer can purchase a payer based in Philadelphia, allowing it to expand into another regional market.
Acquisitions can be friendly or hostile. During a friendly acquisition, the two companies cooperate throughout the process. The organization’s leadership team has accepted the offer and given their approval.
During a hostile acquisition, the management of the acquired organization isn’t in favor of the purchase. The management team might reject the offer from the acquiring company or try to block the sale.
During an acquisition, one organization absorbs the other. In contrast, the two organizations join forces during a merger. A payer merger might involve two similarly sized insurance companies teaming up to create a new, separate, larger organization. A payer might combine with a services provider to create a more robust product offering. Usually, mergers occur between two similarly sized organizations.
After a merger, the two organizations become the same legal entity. For example, if two healthcare payers merge, the new organization might change its name to reflect the shared market or to unify the formerly separate names.
Here are some of the reasons to consider a merger.
Reduce costs: When two healthcare payers become one, they share expenses, which can help save money. For example, the two payers might move into the same office space, significantly reducing the cost of rent. Some employees could become redundant, lowering the cost of labor.
Increase market share: Merging two healthcare payers allows them to increase their market share. The two insurance companies share members after the merger.
Improve patient care: The less work there is for the patient, the better their quality of care. When a healthcare payer merges with a company that provides services such as telehealth, getting access to care becomes much more straightforward. Patients can also feel more confident that their insurance will cover the cost of services they receive from all companies connected to the payer.
What Are the Benefits of Mergers and Acquisitions?
If growth is one of your healthcare organization’s goals, a merger or acquisition can help you achieve it. In addition to expanding your organization’s reach and market share, here are some of the benefits of a merger or acquisition.
Creates a more patient-centric organization: Whether you acquire another payer or join forces with an organization, you can build a patient-focused organization. Expanding the size of your administrative staff by merging with another payer or a healthcare services provider can improve claims processing and increase efficient, accurate billing. An acquisition or merger can also increase the size of your member support teams, such as call center representatives. You can also offer direct services to patients, such as through telehealth nurses and physician’s assistants, creating more care opportunities..
Raises employee engagement: Smaller payers often expect employees to take on extra tasks, potentially leading to burnout. When more people share duties and the efforts of two organizations have combined, the workload lightens. That can lead to more engaged employees who are excited to come to work daily.
Creates more opportunities for your organization: Acquiring another healthcare payer or organization lets you move into regions you wouldn’t otherwise have access to or add services your organization didn’t previously offer. The more geographically diverse or well-rounded your organization is, the further its reach and the more potential it has to establish itself as a leader in the industry.
How to Negotiate a Merger or Acquisition in Healthcare
During a merger or friendly acquisition, you want an outcome that works for both parties. The secret to a successful merger or acquisition is having a specific idea of what you want to gain from it before beginning the process. Knowing what your organization needs to grow will guide you through the process of choosing another healthcare company to merge with or another practice to acquire. Don’t rush the process.
It can be helpful to get outside support during the M&A process. ProspHire’s growth and expansion services can help you develop a strategy to improve your organization’s profits and to secure its future.
ProspHire Can Help Your Healthcare Organization Grow Through M&A
If you’re ready to transform your healthcare organization, ProspHire is here to help. Our business growth and expansion division has experience providing support to organizations that want to grow internally and externally. We work with you to develop a strategy and roadmap to guide you to where you want to be. Contact us below to learn more.
PITTSBURGH, PA – ProspHire, a national management consulting firm focused on healthcare advisory, project delivery and strategic resourcing, announced today an expansion of its presence through the addition of 3,500 square feet of office space in the Philadelphia market to accommodate the Firm’s fast-growing client-base.
The expansion will help to better serve local health insurance and provider systems in the market. ProspHire’s expertise in managed care programs (Medicaid, Medicare and DSNP markets) will be especially relevant to local health plans who are facing challenges with rapidly changing regulations and membership changes because of the “new normal” that is emerging from the COVID-19 pandemic.
Located in King of Prussia, this new, modern office space offers a wide array of meeting areas from enclosed glass rooms with large flat-screen TVs, community seating areas and a town hall area to host larger team gatherings. Additional features include a fully stocked kitchen, TVs integrated with cutting-edge screen sharing and communications systems and community seating for up to 50. Our clients will also be able to leverage these spaces for in-person collaboration while partnering with ProspHire on their engagements.
ProspHire has had tremendous growth since its founding in 2015. “We’re opening the office in Philadelphia at such a vibrant time, hoping to take advantage of the city’s energy and making it easier for healthcare consulting talent to take the next step in their career with us,” said Lauren Miladinovich, Managing Principal and CEO. “We believe King of Prussia is the perfect location for our clients and our employees alike. We’re excited to experience all the area has to offer and expand our business to Philadelphia and the surrounding market.”
Since ProspHire’s inception, the Firm has provided clients with unmatched quality and service and helped a variety of healthcare organizations implement transformational solutions that have allowed their businesses to thrive. The Leadership Team believes that a boutique healthcare consulting firm can truly make a bigger difference in Pittsburgh, Philadelphia and across the United States for healthcare organizations that need innovative, value-add solutions. Being in the Philadelphia market also enables ProspHire to hire motivated practitioners who know and understand local clients. The hope is to inspire them in building closer connections and providing innovative solutions for complex health plan challenges.
ProspHire continues to receive workplace accolades for its culture. In 2022, Modern Healthcare named ProspHire a Best Places to Work in Healthcare for the third year in a row. In 2021, the Firm also ranked in the top ten on the Pittsburgh Business Times Fast 50 List of the Fastest Growing Private Companies in the Pittsburgh Region. Additionally, ProspHire was named an unprecedented 2 years in a row to 2021 Inc. Magazine’s annual list of America’s Fastest-Growing Private Companies – the Inc. 5000.
About ProspHire ProspHire is a national management consulting firm focused on healthcare advisory, project delivery and strategic resourcing. Founded on the core value of relationships, with the goal to “prosper together,” ProspHire partners with clients to identify and solve their most significant people, process and technology challenges. The woman-owned and rapidly growing Pittsburgh-based firm has nearly 100 practitioners and consultants who deliver exceptional service to each one of our clients across the U.S. Visit www.prosphire.com.
SY2022 was the highest performing Star Year on record with a total of 219 contracts improving their Star Rating, while only 3 plans experienced a decrease in performance. This boom time for Star Ratings was driven primarily through relaxed rules within the Rating System due to COVID-19 impacts. These relaxed rules are due to expire for the upcoming SY2023 ratings release. This means that for the first time since SY2021, plans will utilize pure data without the assistance of relaxed rules.
Moving forward into SY2023 and SY2024, every Stars contract will be impacted by additional changes to the Stars Program. These changes, either already in effect or pending to be in effect, have the strong possibility to negatively impact contracts. These headwinds include:
Member Experience Weight Changes 2x – 4x (SY2023)
Tukey Outlier Deletion Impact (SY2024)
Below we provide critical information for Health Plans and Stars Leaders as we approach SY2023 data release.
Member Experience Weight Changes
SY2023 will see the full x4 weight impact of the Member Experience measure changes. ProspHire has spoken about this change in the past and has provided key insights into how Health Plans can deploy strong Member Engagement strategies to significantly impacts Stars.
Health Plans will need to double down on the work they’ve been doing on the CAHPS and Disenrollment measures and continue to focus efforts on ensuring a positive member experience with the Health Plan.
Tukey Outlier Deletion (SY2024 Impact)
Tukey outlier deletion is a standard statistical methodology for removing outliers with the goal of increasing the stability and predictability of the Star measure cut points and ultimately reduce Quality Bonus Payments. Measures that will see the biggest impacts are those with cut points most separated or wide. It is also estimated that by 2030, Quality Bonus Payments will be reduced by nearly $4 billion dollars.
This change will have a dramatic impact on measure performance at both the lower range and upper range of the current cutoff thresholds. According to preliminary analysis by the Federal Register, if these proposed changes would have been implemented for the 2018 Star Ratings, 16 percent of Health Plans would have decreased by half a star.
To provide deeper analysis, our analytics partner, Hyperlift, applied the Tukey methodology to SY2021 data (non-COVID impacted data) to examine the impact it would have had across the health plan landscape. For this article, they used the average SY2021 scores for each measure and showed what the impact would have been. You can see, in this graphic below, that the average plan would have had the Star ratings changed on eight measures (all but one of those changes resulted in Star rating drop), which would have resulted in losing a total of 15 basis points.
At ProspHire, we continue to partner with Health Plans to offer insights, analysis and execution strategies to improve Star ratings. Do you need support to protect against the impending Star Rating decline? Contact us for a free Tukey Impact Analysis specific to your contract.
OIG Study The Office of Inspector General (OIG) recently published a report on a study completed showing significant issues in prior authorizations for Medicare Advantage members. The investigation was sparked by a concern that Medicare Advantage organizations were denying or delaying coverage for procedures and services allowed by the Centers for Medicare and Medicaid Services in both Medicare Advantage Plans and covered under traditional Medicare benefits. In a randomly selected sample, the OIG determined that prior authorization determinations in some cases were not consistent with Medicare coverage rules and Medicare Advantage billing rules. The findings in this study were consistent with previous studies published in 2018.
OIG Findings In this study, 13% of the denied services met Medicare coverage rules. The study provided examples related to decisions for the payor incorrectly time limiting a follow-up MRI scan. Another example was denying a post-polio patient a walker that had previously used a cane. One of the issues identified in the study was the fact that Medicare Advantage Organizations were applying clinical criteria that Medicare does not require.
In the second part of the study, the OIG investigated payment denials resulting in an 18% error rate based on Medicare Advantage billing rules. One of the reasons cited in the study for the issues was human errors during the manual review process. Examples included denial of a claim for a non-par provider in an in-network facility and a reviewer missing a prior authorization that led to claim denial for radiation treatment. Other errors were related to programming issues in claims processing systems, such as incorrectly identifying tax identification numbers or incorrect time-frame identification for coverage. Another was related to a more restrictive policy requiring an x-ray before an MRI or a MRI before therapy. Other treatments were inconsistent with Medicare National Coverage Decisions governing the plan.
The list of issues identified in the study is extensive. The OIG provided CMS with recommendations that will require Medicare Advantage Organizations to consider the similar problems they may have in their prior authorization processes and procedures. CMS agreed with the OIG recommendation to issue new guidance on clinical criteria, update audit protocols and direct Medicare Advantage Organizations to take additional steps to identify and remedy issues in manual and system errors.
How ProspHire Can Help At ProspHire, our team of utilization management experts can rapidly assess your current policies, procedures and processes for prior authorization issues and provide a detailed playbook for addressing problems identified in the assessment. We will help you navigate the issues and mitigate potential audit risks represented by the OIG report. Working with your team, we can support the implementation of the playbook, including updating policies, training staff and executing transformation to processes and systems to remedy potential errors. We will review current prior authorization criteria and improve the accuracy and the workflow issues that may be causing problems. We believe proactive evaluation and execution can limit the risks to the organization while enhancing processes that may be causing issues for the organization.
On April 4th, 2022, CMS released their 2023 Medicare Advantage and Part D Rate Announcement. This notice contained several proposed changes to both methodology, calculation and future measures. However, the short-term impact overall is minimal in 2022 and 2023. Proposed changes could potentially have to go through the rule making process and work take additional time. With each new notice from CMS, plans should always be forward-thinking.
Below, we highlight two critical considerations for Health Plans to be successful in Stars. These take into account future changes to the program and will position your plan to be successful both now and into the future.
HEDIS Impacts – Data Transformation:
CMS has announced that they are removing the hybrid reporting method for Colorectal Cancer Screening in MY2024 and transitioning the measure to electronic clinical data systems (ECDS) reporting only beginning in MY2024. For the Breast Cancer Screening measure, CMS will move the measure away from administrative collection and to ECDS collection beginning in MY2023.
What is the difference between traditional HEDIS reporting and ECDS? The ECDS method has specific guidelines for reporting data to NCQA using four data source categories: EHR, health information exchanges/clinical registries, case management system and administrative claims/enrollment. Contracts will no longer be able to assess performance based on a sample of members when the hybrid method is removed, but they can continue to use data from chart reviews if it is standardized upon abstraction and included in an electronic database. They can perform year-round chart review and have it audited as non-standard supplemental data and use it to report the measure.
Plans need to consider data transformation efforts to shore up their ECDS capabilities if, in fact, CMS decides to migrate all eligible HEDIS measures toward ECDS reporting.
Future Changes to Star Ratings – A Focus on Health Equity
CMS, in its latest ruling, hinted at several potential changes to the Star Rating program, several of which had a focus on Health Equity. These changes would come across as net new measures and calculation/methodology changes.
The biggest takeaway for health plans is not to focus in any one specific new potential measure, but to consider health equity broadly when devising Stars strategies. Forward thinking plans would be wise to consider the following:
Intelligent Data Collection
Plans need to rethink how they collect and document data from members (i.e., on housing security, food security, etc.). Creative plans are thinking about enhancements to Health Risk Assessments, Application Data and other data collection opportunities along the continuum of a member’s journey with the plan.
Community Collaboration
Health plans should consider enhanced public/private partnerships within the communities they serve. This includes improved programs and/or incentives with focuses on social risk factors and assisting members to obtain community resources available to them.
Reminders for Star Rating Measures in 2023 and Future Years:
Measure
Impact Year
Description
Care of Older Adults Functional Status
MY2021/SY2023
CMS removed this measure.
CDC- Kidney Disease Monitoring
MY2021/SY2023
NCQA announced the retirement of this measure after MY2021/SY2023. CMS will consider Kidney Health Evaluation for Patients with Diabetes (Display Page) as new measure with future rule making.
Recently, the Centers for Medicare & Medicaid Services have changed the final calculation to increase the weight of customer experience measures. By 2023, the influence of customer experience metrics will increase to 57% of the final score.1 High performance on customer experience metrics is a significant challenge among health plans, when as recently as 2018, a Net Promoter Score (NPS) score comparison revealed that the health insurance industry had a 19 percent lower score than every other sector except utilities.2
The inability of health insurers to positively impact customer experience leaves them vulnerable to lost revenue and increased customer acquisition costs. More specifically, insurers participating in the Medicare Advantage Stars program compete for $15 billion in additional incentives for those members.2 A significant portion of this Star rating and subsequent reimbursement utilizes customer experience measures, including the CAHPS survey. The need for new, innovative and data-driven solutions in this facet of health insurance is required for insurers to make intentional gains in their customer experience ratings, thereby preventing financial losses due to low retention rates and Star ratings.
At ProspHire, we believe that health plans have the opportunity to improve customer experience through the use of artificial intelligence (AI) and other data-driven approaches. The application of AI in healthcare has dramatically increased in recent years. Forecasts by Business Insider project healthcare spending on AI will grow at an annualized rate of 48% between 2017 and 2023.3 Presently, AI benefits are typically associated with claims processing and fraud prevention, with figures of $122 billion in savings due to automatic claims processing realized in 20204 and a reduction of $527 million in losses due to fraud in 20165. While these areas are driving healthcare forward, how does the healthcare system utilize AI to assist patients with navigating, understanding and utilizing their health insurance benefits, thereby ensuring a positive customer experience with their plan and respective insurance provider?
Personalized Outreach and Product Recommendations for Improved Retention
“People are very careful about how they allocate limited attention and cognitive resources. Particularly when resources are scarce, people tend to have tunnel vision that focuses limited attentional resources to only the most pressing matters. People have less cognitive bandwidth for making decisions or taking action on matters with distant outcomes.”
Lisa Zaval, PhD Limetree Behavioral Science Advisor
One method to improve retention in the health insurance space is to increase relevant engagement with members, specifically those deemed high retention risk. Retail sectors have extended the application of AI to improve customer experiences through personalized marketing and product recommendations to specific groups of customers based upon past purchase history. MA members prefer personalization, with 86% of respondents to an online Harris Poll requesting more personalization to their communications, medical care and services.6 This concept may seem impossible in the healthcare space due to the inherent complexity of the market, but ProspHire has developed an innovative approach for health plans.
ProspHire’s approach involves a partnership of artificial intelligence, behavioral science-based insights and marketing and health plan expertise to deliver a service of the following attributes:
Rapid speed to value
Artificial Intelligence calibrated by industry expertise
Proven, personalized communication leading to member action
Scalability through a user interface that coordinates multiple performance indicators across a variety of stakeholders
Turn-Key Solution for Improved Retention and CAHPS Scores
The competitive health insurance landscape is not a new phenomenon. As a result of this market pressure, most clients have one or many competitive resources, such as AI and machine learning, excellent product design or competitive marketing and sales groups. The reality of bringing all those resources to bear to deliver personalized marketing or product recommendation campaigns in a performance cycle is unlikely. This partnership provides a calibrated AI platform, project management support and tailored interventions with little disturbance to employees’ current duties and responsibilities. Selected interventions can be launched just a few weeks after project initiation.
This program is designed to be self-sustaining and operate adjacent to key business owners and IT professionals at the organization. Once the program is effectively running, it is transitioned back to business owners to manage long-term. There are six essential program components included in this service:
Operations Assessment – Generate hypotheses regarding significant or unique barriers to current performance goals. Identify capacity gaps to address prior to A.I. pattern review.
Data Request and Intake – Ensure general industry and unique drivers for poor retention or CAPHS scores are inserted into the AI Platform.
Behavioral Science Analysis– Identify underlying human judgement and decision-making principles impacting the customer experience or interfering with engagement goals.
AI Platform and User Interface– Calibrated with the assistance of healthcare professionals to identify actionable and meaningful patterns.
Intervention Playbook – A prioritized list of interventions to address capacity gaps in operations, as well as important trends revealed by the AI analysis. Best industry practices and behavioral science approaches will be used to design the interventions.
Program Management – Project support and guidance from initiation through intervention.
Realizing Value with a Team-based approach to AI and Customer Experience
In industries outside of the health sector, 75% of business executives report prioritizing customer experience investment over the prior three years and the next three years.7 Health insurance companies may have a similar commitment, but the results today are not being realized at the level of these other industries. ProspHire, with the partners of Limetree and Unsupervised, can make a noticeable change in retention and CAHPS performance. This intervention not only delivers a quick win within a performance cycle but provides a long-term surveillance system to continually improve these areas. Once a client achieves and maintains the desired level of performance, the platform is easily scalable to other areas of customer experience or general operations. Some of these additional areas can be Stars quality measures, care/utilization management or connecting sales processes to member profiles.
Impact Retention Today
Do not let the current performance year pass before acting to improve key revenue driving metrics.
The Healthcare Effectiveness Data and Information Set (HEDIS), a set of performance indicators, is required by the Centers for Medicare and Medicaid Services (CMS) for all Medicare Advantage plans. It is a tool utilized to monitor outcomes related to clinical quality and preventative care across health plans and has significant impact on Medicare Stars. HEDIS data can be calculated either utilizing administrative data within the claim or encounter, supplemental data, or hybrid data review. Hybrid data requires additional information through medical record review to provide the full picture of the care provided. HEDIS season is the last opportunity to focus on HEDIS measure improvement efforts for Star Year 2023.
Maximizing your Chart Retrieval Process for HEDIS
Performing a review and analysis of the medical records is critical to the success of HEDIS/Hybrid season and maximizing abstraction efforts. Medical record outreach to providers can be completed in multiple ways, such as fax, mail, on-site collection, electronic medical record (EMR) access, etc. From HEDIS pre-planning efforts to the pull of the initial rates, health plans need to be focused and have strategies in place for early and often outreach.
Below we discuss three key themes outlining a successful HEDIS/Hybrid strategy.
Advanced Analytics Support
Completing an initial assessment/impact analysis of the HEDIS data as your initial rates/sample is pulled gives your team a great perspective on the season ahead and allows for strategy development. This enables your team to have a clear understanding of opportunities and strategies to pursue throughout the season.
Plans are encouraged to have reporting to allow leadership insight into performance as the season progresses. This includes chart retrieval goals, forecasting and provider location opportunity analysis, which allows for better communication and more informed decision-making.
Enhance Provider Partnerships
Optimizing relationships with provider partners is extremely important to the success of HEDIS season. Plans typically have internal communications, tools, trainings and resources available to better assist provider partnership.
Continuously updated provider data enables a strong start to the HEDIS season and in turn will help reduce provider abrasion and ensure your requests are ‘first in the door’ with providers.
Plans should also consider creating strong and up-to-date provider repositories. This repository/database will go a long way to help ensure the information is passed from season to season such as a list of providers that require on-site retrieval or providers with EMR access.
Clinical Approach and Review
Having the right clinical abstraction team in place to support HEDIS season is imperative. Ensuring the team is established in prior to the new year, allows for trainings and educations to be completed ahead of the start of the season. This clinical abstraction team will make the clinical connections that can improve HEDIS outcomes.
Performing a second review (over-read) of the medical records at 100% ensures accurate and consistent abstraction with every medical record retrieved.
At ProspHire, we continue to partner with Health Plans, to offer insights, analysis and execution strategies to improve Star ratings. Do you need support to optimize your HEDIS season? We would love to have a conversation. Feel free to reach out to Andrew Bell, at [email protected]. Let’s prosper together.
View Our Infographic on Positive Member Engagement
With the shift in the Consumer Assessment of Healthcare Providers and Systems Survey (CAHPS) and other operational measures weighted from 2x to 4x, a positive Member Experience with the plan is now critical to succeed in Stars. Understanding member’s journey with the plan, end to end, is paramount. In our experience, health plans that listen to the member and proactively react to their feedback often will achieve their performance goals and reach 4.0+ Stars for their contract.
Creating a Culture of Positive Member Engagement – Strategic Approach
Individuals are most dissatisfied when their expectations are not met. The Medicare Program and the Medicare Stars team need to work collaboratively across the organization to ensure that members’ expectations are clearly set, defined, and ultimately exceeded. Mature Health Plans have strong alignment between the management of their products and the management of the Member Experience. From the pre-sales process to acquisition to onboarding and throughout the life cycle of the membership, health plans need to be cognizant of every member interaction to make each touch meaningful and impactful.
Below we discuss four key themes outlining a successful member engagement strategy.
Predictive Analytics and Centralized Data
You cannot fix what you don’t understand and measure. Health plans need to think more creatively about the ways they understand Member Experience at the health plan. Centralizing Member Experience metrics in a database will go a long way to help enable better, more informed decision making.
Understanding your membership – Plans need to consider deployment of micro-surveys, pulse checks, and off-cycle surveys in order to gather key member insights which will inevitably inform your ongoing strategy.
Predictive Analytics – predicting future member dissatisfaction will help mitigate downstream risk. Analysis of member-level predictions can identify opportunities for targeted messaging.
Alignment of Messaging and Synergy Identification
Plans typically have the internal capabilities, tools, and resources necessary to optimize member communications. Internalizing multichannel engagement strategies and leveraging those capabilities and expertise reduce reliance on external solutions and ensure greater governance, data management, and program management.
In heavily siloed organizations, members are often victims of ‘information overload’ due to numerous member outreach campaigns throughout the year. Within these campaigns, there are several opportunities to combine efforts among plan operations that should be considered to reduce member abrasion.
Enhance the Payer – Provider Relationship Potential
Providers are typically a member’s primary point of care, not the plan. Plans should optimize their provider relationships as it can have deep downstream impacts on CAHPS and satisfaction. This includes understanding a member’s care journey, medication history and other relevant experience information.
Positive Feedback Loop – keeping providers informed and engaged is key. Plans need to educate providers about what you are asking your members to do in addition to the incentive opportunities they may have. Lastly, plan product design changes can impact providers, and proactively informing providers of changes and their impacts can improve engagement.
Benefit and Resource Optimization
In a highly competitive Medicare landscape, optimized benefit design and reward or incentive programs can significantly impact Member Experience while also impacting other domains (i.e., HEDIS, HOS, PDE, etc.). Plans can also empower their supplemental benefit providers to bolster the member experience across existing touchpoints (and therefore avoid the need for additional outreach).
Health plans invest a lot of money into programs and resources that members either are not aware of, or not capable of connecting with. It is the health plan’s job to proactively form those connections, to improve satisfaction and engagement.
At ProspHire, we continue to partner with Health Plans, to offer insights, analysis, and execution strategies to improve Star ratings. Have you considered your own health plan’s member engagement strategy? We would love to have a conversation. Feel free to reach out to me, Andrew Bell, at [email protected]. Let’s prosper together.
