Be Rewarded – Or Penalized - Begins Jan 1, 2023
· Your Doctors and Hospital Face Unfeasible CMS Requirements (Working Without Help)
· We Help Eliminate the 9% Penalty - and Build and Grow Your Organization, Now and Moving Forward
· You incur no labor cost; there is no need to learn coding. We run a report for you - and you decide what you want to do from there.
· Our system puts the focus on remote engagement to triage who needs to be brought into the office.
· You gain more time, more income, healthier patients and even decrease your RAF Score
TEN REASONS HEALTHCARE EXECUTIVES
ENGAGE THE PROGRAM
1. THE PLATFORM starts by showing exactly
how CMS currently grades each provider and
identifies what mandated services and revenue are
missing for Fee-for-Service beneficiaries.
2. THE PLATFORM maximizes compliance and
revenue in the Medicare Fee-for-Service world by
providing medically necessary services in the
background away from the practice workflow.
3. THE results are uploaded or
dragged and dropped into the provider’s
EHR with no integration needed.
4. The technology also specializes in Medicare
Advantage (MA), Accountable Care Organizations
(ACOs), and Medicare Shared Savings Programs
(MSSPs). Risk Sharing Specialists
(PRSS) division, is directed by our C-level executive,
a former market president for one of the largest and
top MA plans nationally with over 15 years of direct
experience turning around failing MAs and ACOs.
PRSS division has taken this knowledge and
expertise a significant step further with sophisticated
algorithms that our technology automates allowing
for a much greater impact. This is how THE
PROGRAM assures even greater success.
5. THE PROGRAM also targets and provides
metrics and engagement on commercial, self-insured,
or cash pay patients/beneficiaries as well.
TEN REASONS HEALTHCARE EXECUTIVES
ENGAGE THE PROGRAM
6. THE PROGRAM has four technology/patient
engagement offerings to choose from. Many clients
use all four offerings depending on their specific
7. THE PROGRAM has a one-of-a-kind Series LLC
through A Risk Share Cooperative that allows It to
break out providers based on risk preferences,
provider performance, and patient complexity
recognizing the risk these patients present to the
success of these programs.
8. We work with underwriters and sponsors such as
Assar, Wellvana, Humana MA, Centene MA, BCBS,
BCN+Risk, Priority Health MA, Sedara, and growing.
The program through these offerings are able to place
providers under the groups/umbrellas so that
providers either isolate their risk or allow them to
maximize shared gains by not having them dragged
down by poor performers.
9. THE PROGRAM provides four individual
revenue silos to providers: a) Fee-for-Service,
b) Capitation, c) Shared Risk, and d) Provider
Compliance Rewards which are group discounts and
incentives that are applied back to the
bottom line of the Series LLC entities.
10. THE PROGRAM'S traditional services have no
upfront cost, and nothing is owed until after insurance
The programs One-of-a-Kind Proprietary Technology identifies care and compliance gaps, then provides the care coordination and compliance steps required based on the CMS Standard of Care. It then goes one step further by interweaving all other measuring metrics such as MACRA/MIPS/STAR/HEDIS/QCM.
The platform is also able to pivot by payer to any of these desired measures. No integration is needed, nor will the provider ever even login or see our system as we operate in the background away from the staff and office workflow.
By leading with our technology, we are able to save millions of dollars in labor by simply electronically triaging those higher risk patients needing to see their provider, while continuing to manage the healthier ones remotely. This allows us to focus our labor dollars on specific high touch encounters.
The Virtual Support Network (VSN) is a national network of healthcare professionals consisting of physicians, PAs, NPs, MAs and health coaches that allow providers to extend their office staff and bandwidth without upfront cost to the practice.
At a time when it is difficult to find or retain staff, much less find the resources to pay them, the platform literally has tens of thousands of these VSN professionals. Once they complete the medically necessary tasks remotely on behalf of the provider, the results and notes are simply dragged and dropped or uploaded into the EHR.
All work is then submitted as a superbill directly into the provider’s gateway clearinghouse on their behalf, along with all notes and documentation required to support the claim.
Opioid Management (and Opioid Addiction Prevention Program):
1. The service, provided by a technology/case management firm, has a patent-pending solution using predictive analytics to identify clinical prescribing patterns that are known to add seemingly unrelated healthcare costs due to opioid withdrawal symptoms and saves up to 11% of TOTAL plan cost (pharmacy & medical).
2. Case Study Results: Pursuant to this service, 98% of providers adopted CDC guidelines for opioid prescribing which resulted in 37% reduction in ER visits, 84% reduction in Hospitalizations, and 41% reduction in provider visits.
4. Plan members’ identities are NEVER disclosed, even to their healthcare providers, and plan members are NEVER contacted. Therefore, there is absolutely NO member disruption.
5. More than 50% of opioid prescribing is done by healthcare providers with no formal training in pain management and up to 80% of opioids prescribed are written by these providers.
6. Thirty percent (30%) of plan members prescribed opioids experience withdrawal symptoms and incur costs that can reach 15% of the total plan cost (Pharmacy & Medical) annually, and 75% of those costs can be eliminated.
7. The service is PBM agnostic; and except for a monthly claims data file, does not need the involvement of any PBM.
8. Typical ROI is 20:1.
2. Built around a unique financial model for Client equity sharing, with dividends and board seat potential.
3. Complete infrastructure and staffing provided where Client receives control of their Rx benefit without additional cost or headcount.
4. Provides best-in-class modular services components and manages them under one platform to enhance cost containment and quality of care.
5. Comprehensive PBM-like services including claims adjudication, retail network, mail order, specialty drugs, clinical management programs, customized formularies, rebate contracts, and member services.
6. Fully transparent and pass-through pricing delivered via a drug-mix that supports a lowest-net cost strategy without sacrificing quality of care.
7. One simple administration fee provided on a per Rx or PMPM basis.
8. Provides the Best Client Services Agreement, which employs the type of language, provisions and definitions consultants want because it favors the Client and their members rather than a PBM.
Patient Assistance Programs (PAP) is a Non-Insurance Program in which high-cost drugs (specialty drugs, etc.) are provided from drug manufacturers directly to plan members at no cost to plan members and significant savings for plan sponsors.
Option 1: White-Labeled Concierge Service as an outsourced, back-end Patient Assistance Program
Option 2: Web-based software for Patient Assistance Programs to execute your own in-house PAP programs. Provides the tools not only to populate all the drug manufacturer applications, but also to track where the application is in the process and provide refill reminders. Includes reports that deliver information on orders, refills, renewals, and patient and doctor data that also pertain to the PAP application process.
Ø Both options include the provision of approximately 4,500 Diagnosis-Based Assistance Programs.
1. Clinically Precise: Evidence-driven therapeutic alternatives databases optimize prescriber adoption of lower cost, clinically appropriate medications and thereby facilitate greater savings for members and plans. Each therapeutic class undergoes a rigorous clinical evidence evaluation that accounts for medically accepted uses, evidence-based guidelines, head-to-head clinical trials, outcomes studies, adverse effects, contraindications, warnings, and any unique features of each drug.
2. Comprehensive: Therapeutic alternatives database covers 124 therapeutic drug classes, over 6,539
medications and 29,499 “perfect drug pairs” to the GPI 14 level.
3. Plan Specific, Lowest Cost: Plan and Formulary specific alternatives that align with existing plan discounts, Mac lists, benefit designs, formulary rebate and trade agreements and provide accurate ingredient and plan costs, along with member copay amounts, displaying up to four (4) therapeutic alternatives. Typical savings are 15%-20% off total drug spend, reported at the plan and therapeutic class level.
4. Timely and Accurate Updates: Weekly updates across the entire database keeps all 124 therapeutic drug classes timely and accurate.
5. Use Cases: RTBC-real time benefit check, Member and portal apps, Clinical utilization-MTM, Formulary modeling, Claims analytics, Medicare Part D EOB’s, and Value based reimbursement-DAW penalties.
1. Enables pharmacy care management initiatives including MTM via their digital platform for Pharmacist and Patient collaboration, as well as ability to augment existing clinical resources with their own network of Pharmacists.
2. Provides digital tools for Pharmacists and Patients that have been built following Minimally Disruptive Medicine (MDM) principles to reduce the work associated with self-care management at home. The robust clinician platform and patient app (API-only available as well) as well as automation tools help pharmacists with patient monitoring, productivity, better data, and ease of communication with their patients via video and chat.
3. Using automated, clinically based medication management and safety checks with a structured daily routine that is configurable by individual care needs, immediate resources are provided within the app to ensure accessible support such as reaching a licensed pharmacist for answers.
4. Achieve simplified health and medication education is provided to reduce costs due to medication nonadherence, adverse drug events, and related ER admissions while optimizing care quality (STARS and HEDIS) and increasing patient-clinician communication and member experience.
5. Expect a 5:1 ROI
2. Removes concern about the conflict of interest of PBMs that own specialty pharmacies and make prior authorization approval decisions. “PBMs now earn more than 50% of their profits from specialty drug dispensing activities”, Drug Channels Institute, May 29, 2019
3. Prior Authorizations based upon medical necessity, not FDA approval (lowest minimum threshold approach) and drug manufacturer dictates required to achieve higher rebates.
4. Applies evidence-based defined therapeutic criteria to determine appropriateness of specialty prescriptions for patients based on the type of specialty drug, the patient's condition, and the need for the drug. Certain approval criteria may require genomics or additional lab testing.
5. Typical ROI ranges from 15% - 45% reduction in total pharmacy spend.
1. Provides drug coverage recommendations and customization for an evidence-based, lowest net cost formulary. Targets both low value brand drugs and high-cost generic drugs.
2. Provides a proactive mechanism, reference-based pricing, to incentivize plan members to more cost- effective medications with a 90 – 95% conversion rate.
3. Ensures access to medications proven safe and effective while providing cost control.
4. Removes concern about the misaligned incentives of traditional rebate maximization models.
5. Typical ROI ranges from 8% - 15% reduction in total pharmacy spend.
1. Consumer cloud-based education and awareness solution using push technology to notify patients about lower cost equivalent medications. Ideal for high-deductible health plans.
2. Lower out-of-pocket cost for patients and extends the time to meet plan deductibles.
3. Typical ROI ranges from 2% - 3% reduction in total pharmacy spend.
1. Real-time automation across the entire pharmacy benefits eco-system to autonomously analyze every Rx claim individually and in aggregate to identify problems and opportunities and provide instant alerts of anything outside previously defined parameters.
2. Automatically compare the cost of drugs against all possible alternatives (optimal rebate payment, generic equivalent, therapeutic alternatives) to quickly identify the lowest net cost.
3. Real-time access to rebate reconciliation enables users to easily track incoming monthly payments of rebates, rather than quarterly or six months later. The level of access, transparency to the NDC level, and automation decreases the rebate processing and payment time by 66%.
4. Industry-unique pharmacy rebate solution bypasses ownership fees, provides 100% pass through transparency and NDC 11 claim detail, and typically yields a significant increase in rebate dollars.
1. Using sophisticated, science-based technology, the firm’s pharmacist care teams identify patients with an increased risk of medication-related health burden that adds cost to employer medical and pharmacy programs.
2. The firm’s goal is to optimize the health of patients by improving the capacity of their medication regimen for optimal health results.
3. The personalized attention to patients ensures the best possible outcomes and incorporates prescriber and patient involvement.
4. Typical ROI is 3:1 and varies by solution.
The average ROI for clients is 7:1 with savings opportunities coming from 5 buckets:
15% of Total Savings
15% of Total Savings
15% of Total Savings
20% of Total Savings
35% of Total Savings
Guarantee: Savings of at least the amount of the entire annual fee is achieved or there is no cost to the employer.
1. Waste, fraud, and abuse are prevalent due to a system due with misaligned incentives and conflicts of interest.
2. The services produce an immediate ROI by providing plan sponsors full transparency on physician, pharmacy, and patient performance by monitoring for optimal dispensing patterns that fall within evidence-based guidelines.
a. For patients, the service provides an optional mobile app that allows them to diary adherence, exacerbations, etc. (85% of patients are highly engaged and diligent loggers).
b. For payers, pharmacies, and clinics, the service provides a web app that allows them to document high quality data that is outside of claims data which include script information, pharmacy shipment information, lab values, patient interactions, along with being alerted to anomalous patient behavior and documented exacerbations.
c. Combining the data streams enables deep insights into the benefit and the level of disease state control, as well as the ability to audit physician performance, pharmacy shipping performance, patient utilization patterns, etc.
Typical ROI is 4:1 or ≥ $40K per patient per year.
Copyright © 2023 A3 - All Rights Reserved.