In our recently published white paper, Disclosure, Transparency, and Fiduciary Responsibility, we describe the importance of enhanced disclosure, strong diligence, and heightened audit practices that are enforced by well-written contracts to ensure alignment and accountability among key health industry stakeholders. Risk Strategies Consulting strongly advocates that healthcare stakeholders change the underlying dynamic to one of transparency, and this includes having a complete understanding of value and cost. Those of us in the industry simply cannot achieve collaboration if we cannot trust one another and advocate for disclosure respective to our focus areas.
Plan sponsors depend on consultants to use their expertise and experience to properly serve and protect them. The consultant’s role is to bring subject matter expertise in aiding and ensuring clarity of the costs of potential health plan/ pharmacy benefit manager (PBM) bidders. A requirement in a request for proposal (RFP) must be that bidders are as transparent as possible in their responses.
Risk Strategies Consulting has described the critical need for transparency and disclosure within healthcare. A key part of our value proposition to clients is our multi-disciplinary team’s ability to highlight for them the true value proposition of their benefit structure through achieved per member per month savings, utilization patterns, patient condition and provider mix, local market and delivery system conditions, clinical management and quality outcomes, and member experience, creating an elevated awareness of their direct and indirect costs and benefits and how these will advantage their employee population’s health journey. We accomplish this through a variety of channels such as requests for proposals, contract negotiations, vendor management, reporting, analytics, and our auditing framework that is inclusive of administrative, clinical, financial, operational, and compliance aspects.
With this framework, our self-insured, plan sponsor clients can have greater confidence that they are meeting their fiduciary responsibilities on behalf of their employees and are being well served. Soon, you will also have an opportunity to read another Risk Strategies Consulting white paper, Healthcare Audit and Payment Integrity, which features our comprehensive audit and payment integrity (PI) platform that we consistently execute. We utilize needed tools and protocols to enable ourselves or other third parties to audit our calculations, methodologies, and results and to understand, not only if someone is succeeding, but how and why. For Risk Strategies Consulting, this audit process is our means for looking for continuous improvement and growth.
Health plan/ PBM use of antiquated, disconnected claims systems; the existence of tired business processes; and the growing array of specialty and pharmaceutical codes that are variably utilized by health plans/ PBMs are less than optimal, and generally, detrimental. An additional area that is not always clear to plan sponsors is how fee-for-service and value-based reimbursement coincide or complement the quality and savings value propositions of health plan networks and vendor-contracted solutions. Risk Strategies Consulting believes these factors, amongst many others, need to be addressed head-on. Best-in-class consultants must focus their questions to clients, vendors, and health plans to ensure they are adeptly asking the right questions, while also illuminating those they have not been, but should be asked.
To demonstrate our commitment to drive solutions to these key issues, Risk Strategies Consulting has developed an in-depth questionnaire, Comprehensive Commercial Network Quantification and Enhanced Uniform Data Specifications, which has been prepared for health plan and PBM completion and submission to Risk Strategies Consulting. As the document describes, the objective of obtaining this information from health plans and PBMs is to clearly and specifically state the types, amounts, frequency, transmission methods, and purposes for any disclosed and/ or undisclosed costs and revenue streams that impact cost or value of healthcare for a self-insured plan sponsor -- by any channel. This way, we are discerning all direct and non-direct charges to the claim file and bank accounts of any self-insured medical or PBM client for appropriateness and accuracy. Our questionnaire is also designed to ensure disclosure of all additional revenue sources being earned by a health plan that has an impact on the client. Each of these sources is examined for the individual client and is also compared to the health plan/ PBM’s book of business norm. Please know we plan to deploy this tool with all existing clients and upcoming RFPs.
The Comprehensive Commercial Network Quantification and Enhanced Uniform Data Specifications Questionnaire is our first attempt at working through this type of in-depth disclosure with health plans and PBMs. Risk Strategies Consulting is publishing this questionnaire in an open-source fashion so that the market can respond. We sincerely welcome your input and are seeking your suggestions for improvement. Together, we can all arrive at full and accurate conclusions.
Our strong position is that ensuring transparency, clarity, appropriateness, and accuracy of the content and impact of all direct and non-direct health plan and PBM revenue that impact plan sponsors is highly important for them to responsibly understand, manage, and make strategic decisions regarding benefit administration on behalf of their employees. We believe this initiative will help plan sponsors to not only understand their total costs and value of a given health plan offering, but also help ensure compliance with their fiduciary responsibilities. Comparatively, we also believe this will assist health plans in better describing their true costs and value propositions and to build greater trust with their clients.
Learn more about Risk Strategies Consulting or email us at riskstrategiesconsulting@risk-strategies.com.
