Helping Your Providers Assess Their Ability to Take Risk

We have often noted when a team works well together, it can collectively accomplish more than its members alone. This adage has never been truer than the looming Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) legislation and the steps providers will need to take to make a successful transition.

Your network providers, especially the individual and small groups, have been inundated with and trying to digest huge amounts of information from all directions on how to prepare for the changes that are coming. A significant portion of the information providers have received on where they rank compared to their peers on quality metrics has come from benchmarks established by the health plans with whom they are contracted. It also is understood providers have been wary of the data they have received. Real-time, transparent data has been at the top of the list for providers when building trust and long-term partnerships.

As health plans, we have focused on designing incentive plans to promote compliance with regulatory requirements but to also meet our clinical and financial goals. To remain provider centric, it is imperative we as plans understand where providers are, not only in their ability to take on risk and make the shift from fee-for-service to value-based reimbursement, but also in their overall infrastructure. During various projects, we have shadowed highly-skilled provider relations representatives as they travel in the field to meet with office managers and providers. Often we have found plans have wrong office addresses, the lack of staffing makes it difficult for the office to have time to digest the information we are sending, or it is not getting into the hands of the correct person. The lack of correct provider demographics affects the ability of your risk adjustment team to gather the information they need in a timely manner.

Another observation to note is while your representative is there with the best of intentions to review provider data and offer suggestions on how to improve and capture bonus dollars left on the table, they are one of many reps sitting in the office vying for a minute to talk with the office staff. It is a juggling act for the provider to be able to provide top-notch clinical care for his or her patients and meet the demands of a new value-based world. In order to ensure your largest asset is prepared, why not empower your network with a checklist on how to evaluate their practices?  We have provided a comprehensive checklist providers can utilize to examine the skills, knowledge, systems, and questions they should ask themselves when evaluating their ability to navigate the new reimbursement landscape.

Gorman Health Group is poised to assist your plan in developing a fully engaged provider architecture to ensure the cross-functional needs of all your department “asks” come to the provider at the right time for shared success.



We have provided a comprehensive checklist providers can utilize to examine the skills, knowledge, systems, and questions they should ask themselves when evaluating their ability to navigate the new reimbursement landscape.

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Elena Martin
Elena Martin

Elena Martin is Senior Director of Provider Strategies at Gorman Health Group (GHG). In this role, she has acted as Project Manager for numerous network expansion projects on a national level and has been a key consultant in Accountable Care Organization (ACO) and End-Stage Renal Disease Seamless Care Organizations (ESCO) application and development.

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