> Managed Care

ProHealth At A Glance: Managed Care:

While ProHealth is not a health plan, more than half of our patients are covered by private health insurance. In recognition of the dynamic nature of the healthcare environment, ProHealth has proven our ability to effectively represent ProHealth’s physicians. Our managed care leaders provide both strategic planning and operational support related to the participation agreements we negotiate on behalf of our providers. In a market where health plans and other payors continue to consolidate, we have consistently demonstrated positive differentials in reimbursement rates and customer service.

ProHealth’s Managed Care Services:

• Contracting
• Credentialing & Provider Relations

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Contracting

The objective of our contracting team is to make sure that our physicians are appropriately rewarded for the value that they deliver to our patients and to our health care partners. At ProHealth, we review each agreement to determine whether the terms provide the same protections and rights for physicians as they do for the managed care organization. Beyond qualitative review, ProHealth completes an in-depth quantitative analysis of the financial terms, which is important to assess the viability of the contract.

Our primary care composition ensures that our constituents receive the full benefit of our contracting efforts. Negotiations address variables including:

• professional liability insurance premium increases
• cost of labor adjustments
• profitability

By ensuring that our negotiated rates address these variables, we enable our practices to invest in additional clinical performance improvements that provide value to our patients and providers, as well as our business partners. Our track record of delivering such value on a consistent basis has enabled us to secure contract terms that are consistently more favorable than those offered to the market.

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Credentialing & Provider Relations

ProHealth centralizes credentialing and provider relations activities for all practitioners, including physicians, nurse practitioners, physician assistants, and physical therapists. A physician-led Credentialing Committee oversees the credentialing team, and reviews new providers, changes in status of existing providers, and creates policy recommendations that are evaluated by the Board. Provider Relations is an additional service that is included in managed care operations, and provides significant value and benefit to our providers and health care partners.

A designated credentialing specialist manages the credentialing and re-credentialing processes with each of the health plans and/or agencies with which the physician participates. All of ProHealth’s credentialing data is housed in a customized database that enables efficient retrieval of information. As a result, the credentialing process is more efficient, data errors are reduced, and possibility of disruption in a provider’s participation status is minimized. Our provider relations staff can address questions about fee schedules, contract terms, and a variety of other pertinent issues that involve one of our participation agreements.

Both functions benefit our providers by improve practice-site efficiency and reducing errors. This enables ProHealth practitioners to focus on the delivery of health care services and remain in good standing under each participation agreement.

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