Partnerships

Can you give us a brief overview of Quality Care Partners and your role within the organization?

Cindy Baker, BSN, MSA

Quality Care Partners was founded in 1995 as an organization to bring physicians and hospitals together to create infrastructure to manage care, as well as an entity to focus on third party opportunities for risk and managing risk. I’m the CEO.

What are the primary services that Quality Care Partners provides and what distinguishes your approach in the healthcare industry?

Cindy Baker, BSN, MSA

We’ve created a network of select providers across Ohio to partner directly with employers. We have been doing direct provider contracts with employers since 1996. Most of our audience are self-funded employers.  We help employers, physicians and hospitals understand each other’s challenges, what drives health care spend and how to best control it.

We believe this sets us apart; helping employers understand what goes into the cost of health care and understanding how they can contribute to driving down spending by aligning benefit design to incentivize members to utilize the lower net cost sites of service or service types.

We have built medical management services around cost containment strategies so that we would not just be creating a network to provide great contracts and discounts but also be able to combine the strength of clinical expertise and advocacy for patients. This enabled patients to go through the system in an efficient way and get to the care that they need in the most cost-effective way.

How did the partnership between Quality Care Partners and ClaimsBridge begin, and what were the initial goals?

Cindy Baker, BSN, MSA

We were given an opportunity to work with ClaimsBridge because we are part of a statewide

initiative which aligns three provider sponsored networks to create a statewide Ohio preferred provider network. Our organization was one of the founding Members and remains one of three partners with Ohio State Health Plan and Ohio Health Choice. ClaimsBridge was contracted as our traffic cop, or the data integrator and aggregator. They provided us with a third-party infrastructure to manage all of the claims and point all of those claims in the right direction.

Quality Care Partners separately contracted with ClaimsBridge to manage all the repricing for the contracts we hold with our providers. Since 2012, ClaimsBridge has efficiently applied multiple methodologies for pricing provider claims. Their technology has allowed us to apply Medicare pricing methodology to the specificity of the then current actual provider CMS tables assigned to that provider rather than a blended aggregate rate. QCP is enabled to be creative with contracting and be the liaison between the provider and Third-Party Administrator to create a seamless, efficient, accurate price. Providers have the assurance that they are getting paid the contracted rates.

What key benefits has Quality Care Partners experienced through their collaboration with ClaimsBridge?

Cindy Baker, BSN, MSA

I think primarily for us; it’s being able to manage the entire claims pricing process and have a backroom partner that has truly all of the tools and resources to give us the ability to be competitive in the market.

We’ve been able to design multiple product network configurations and they’ve been able to manage the sourcing of those claims to all   the average turnaround time from receipt from clearinghouse to electronic submission to TPA is less than one day.    It allows for an integrated, one-stop shop, where claims go through one portal, and   never has to leave that portal. Whether it’s in-network, out-of-network   or is eligible for a Qualified Payment Amount, it can be priced before returning to TPA ready to adjudication.

If there are alternate networks, such as our statewide Ohio network, Ohio PPO Connect, those claims are forwarded electronically to those alternate entities without it having to pass through multiple vendors’ hands. It creates a vertically integrated solution for our clients. This works extremely well and allows QCP to keep costs lower for employers/plans.

Turnaround times are remarkable. We’re less than a day on an electronic clean claim coming into the system, is repriced and goes back to the third-party administrator. The paper conversion has also been under four days on average year over year.

Can you share an example, or can you bring to mind a specific challenge that ClaimsBridge helped you overcome?

Cindy Baker, BSN, MSA

First is ClaimsBridge’s ability to address compliance issues with the Consolidated Appropriations Act with the MRF file requirements. They have been our solution for all things related to that, as well as out of network pricing solutions for our clients.

Second is their ability to do true Medicare based methodology. There are many tables involved when contracts are   written to price to Medicare. For a hospital, there might be 13 different tables that have to be downloaded. It’s not as easy as saying, there’s a rate for this hospital in Kansas City, and that’s the rate that you would pay everyone in Kansas.  Specific rates and methodology are applied and current.

ClaimsBridge pricing infrastructure allows applications which are true to today’s Medicare rate. Providers state that competitors’ contracts may state they are pricing Medicare, but it’s the day you signed the contract, and they don’t want to update the tables ever.

How has the integration of ClaimsBridge’s solutions impacted your operations and the services you provide for your clients?

Cindy Baker, BSN, MSA

ClaimsBridge has enabled us to have a one-stop vertically integrated solution and provide industry expertise behind us, so we didn’t have to build it.

We rely on their technology and expertise very heavily to keep us in front of the market and keep us moving forward in meeting market demands. They additionally have relationships with multiple health systems around the country to allow QCP to meet the needs of employers out of state members at market favorable rates.

What improvements in efficiency, or cost management have you observed because of this partnership?

Cindy Baker, BSN, MSA

I think it’s the ease of the contract administration and implementation.  Efficiency is obviously the flow of the claim and the turnaround time to ensure TPA’s have the correct information they need to adjudicate the claim timely, and providers’ payments are not delayed.  Providers that can reduce administrative time in revenue management are more likely to partner with employers for more favorable pricing.

QCP has used our ability to get access to Medicare pricing to get better results for our employer clients. We can leverage the information that we have to be able to steer patients into the lower cost alternatives.

In what ways has ClaimsBridge’s technology enhanced your ability to meet your clients’ needs or achieve your strategic objectives?

Cindy Baker, BSN, MSA

The challenges that we were having prior to our engagement with ClaimsBridge were related to the multiple methodologies that can occur when we contract with providers. When you have multiple methodologies within one provider contract it is very difficult to build all of that technology, keep current and manage it correctly.  Additionally, providers want to know what payment they can expect and trust.

Providers need to trust that claims will be administered in accordance with their contract terms. That’s one of the primary reasons  we wanted to bring this in-house and be able to manage it ourselves. ClaimsBridge technology gives QCP the confidence we need to work with providers and employers on benefit and contract applications.

As you look ahead what are you excited about regarding the continued collaboration between Quality Care partners and ClaimsBridge?

Cindy Baker, BSN, MSA

I think what we find most beneficial with ClaimsBridge is they are very like-minded to Quality Care Partners. They’re looking to build business strategies with us that will help us stay relevant and to be market competitive as we move forward. QCP aligns with partners that have vested interest in our growth and want to be part of mutual success. Kevin Gibson and his team are open to ideas and they’re eager to look at ways to continue to build not only for QCP but for all of their clients.

Is there anything else you’d like our audience to know about Quality Care Partners in closing?

Cindy Baker, BSN, MSA

IQCP has developed over the last 15 years to greatly expand our footprint in Ohio and services. Established and founded in southeast Ohio, we have an extremely strong network and are proud of the employers and plan administrators that have entrusted us with their plan partnerships. We’ve been able to maintain and grow relationships because we are provider-centric, we’re managed and governed by physicians and employers, and that gives us a different view on patient care and contracting.

We understand the payment methodologies. We understand challenges from both sides of the table when it comes to healthplan compliance and spend. We understand we’re spending the money of an employer every time a decision is made, and we like to partner with providers and vendors that understand that as well. Our whole goal is to provide low net cost to employers and find business partners that are also interested in keeping costs low for employers. Clean and efficient administration of customizable solutions brings higher value to our clients.

We understand the payment methodologies. We understand challenges from both sides of the table when it comes to healthplan compliance and spend. We understand we’re spending the money of an employer every time a decision is made, and we like to partner with providers and vendors that understand that as well. Our whole goal is to provide low net cost to employers and find business partners that are also interested in keeping costs low for employers. Clean and efficient administration of customizable solutions brings higher value to our clients.

When did Aequum begin its partnership with Client’s Bridge?

Christine Cooper

We’ve been working together for more than five years now, I believe. It arose out of another relationship and really grew from there.

We got to know each other, got to know Mike, got to know Kevin, and ultimately, because of the work that ClaimsBridge does and the work that we do, we fit together very well as partners.

What are the main services that you provide to ClaimsBridge clients?

Christine Cooper

We provide legal advocacy services, patient advocacy services. We defend balance bills for any plan participants who go to a provider and receive an egregious bill.

We have a partnership with Koehler Fitzgerald, which is a national law firm. We have attorneys there that are defending these bills, but we also have a robust customer service team that is building relationships with the plan participants that ClaimsBridge refers to aequum.

Now that there’s the No Surprise Act, we are also providing services directly to the plans to assist with defending the IDR (independent dispute resolution) claims.

Why do you like working with ClaimsBridge?

Christine Cooper

We love working with them. I think everyone on the ClaimsBridge team is great. Our organizations are aligned in our goals and our mission, reducing health care costs and bringing innovative health care plans to self-funded employers to help attract and retain employees, but also getting good health care plans to the employees themselves.

The ClaimsBridge team is very responsive. I think we’ve just built a really good relationship over the past five years.

There’s the good work that ClaimsBridge is doing as far as doing the repricing and the direct networks that truly help the patients whom we are ultimately on the tail end working with.

It’s just it’s been a very healthy relationship.

Thinking about the totality of the services that you provide, what would you say is the gap in health care that you’re addressing and has that shifted in the last few years?

Christine Cooper

The gap that we’re addressing is advocating for and defending patients when they get excessive medical bills. They get scared and they don’t know what to do with them.

They go to collections and that’s very intimidating for many people. More specifically, we’re alleviating the stress that those plan participants have arising out of any balance bills, or large bills that they’re receiving, any out of network bills, things of that nature.

At aequum, we step in and provide legal representation to the member. The providers then communicate directly with us. The collection agencies correspond with us. And in turn, we have our customer service team that’s communicating with the plan participants. So lifting the burden off the plan participant is one of the gaps that we’re filling.

We also help the employer in their HR function because now you have plan participants that are coming to us instead of taking up time with the HR team.

I would say those are the two primary gaps we address. The other thing is relative to the No Surprises Act. We bring some clarity to the plans so that they know how to respond and we make sure that they’re in compliance with any of the NSA requirements.

And taking the burden off their plate, for both the TPA’s and the plans themselves, we’re handling the open negotiation notices or putting together the packets of information that go into the notice of offer for the actual arbitrations.

How have you seen the impact of the No Surprises Act play out for health plan providers and TPA’s?

Christine Cooper

Right now, the No Surprises Act is still very much a mess and I think there’s a lot of confusion.

The timelines have been constantly moving, the expectations have been constantly moving, so it’s difficult for a TPA or a plan to stay on top of all that.

This is a shift for the plans that Claimsbridge and aequum are working with.

The first issue is whether these claims are even eligible for the process because these providers are putting so much through that really doesn’t even belong in the process to start with.

The second question is: “gee were things paid properly?” So, the problem is overuse of the process by the providers instead of going through the channels that they really should be going through – for reference-based pricing plans that would be balance billing the member (which allows for a strong defense against the unreasonable bill)

And the IDR entities, those arbitrators that are selecting who’s winning and who’s losing are so overworked that from their perspective, I can’t imagine what it’s like to wade through these claims.

You’re getting a lot of inaccurate results and challenging results. The interesting thing, though, is there’s absolutely no enforcement provision and there’s some litigation out there about this right now.

It’s the wild, wild west, and I don’t think we know how this is going to shake out. And I don’t think we’re going to know how this is going to shake out for quite some time. But, from a claim eligibility standpoint, what we’re seeing is claims being dumped into that process and claims that we’re handling or that ClaimsBridge is referring to us, dumped into that process that have no business being there. As a result, one of the things that we’re frequently doing is challenging the eligibility of those claims.

Tell us about a success story that you’ve had for a ClaimsBridge customer.

Christine Cooper

Most recently we received a full write-off for one of the plan participants. The bill was about $4,000. Ultimately, both the plan and plan participant save and such success increase plan participant buy-in on this more innovative plan structure.

Any time we’re getting a full write-off, which we’re seeing more and more, that’s a big success, no matter the size of the bill.

The other is of the claims that we’ve handled for the IDR process that have resulted in a decision, we’ve had seven claims that were deemed ineligible, and that’s the very first argument we make in the process. Getting those claims timely kicked is a success under the No Surprises Act.

Anything else that you’d like to add?

Christine Cooper

I think that just the one thing that I would add is ClaimsBridge has been very attentive to the changes in in the healthcare environment.

I’ve really enjoyed working with Kevin and Mike and others on the team and staying on top of and ahead of those healthcare issues we’ve been discussing. And our partnership has been fabulous in addressing a lot of these health care issues that are ongoing.