Cost and Utilization Management

Example Project: Implement Managed Care Networks

We were involved in developing and implementing some of the first preferred provider organizations (PPOs) on the west coast for self-insured employers. We contracted with hospitals, physician groups, and solo practice physicians. We worked with third party administrators (TPAs) to administer the PPO network and other cost management programs (e.g., utilization review, large case management, controls for unbundling and upcoding of services). We established fiduciary standards and responsibilities. The initial PPOs were developed in the mid-to-late 1980s. The PPOs provided coverage for about 100,000 self-insured individuals (employees and dependents).

Experience

• Worked with large employers to develop, implement, and monitor inpatient utilization review programs, PPOs and other managed care networks (e.g., mental health networks), large case management and disease management programs, and continuous quality improvement programs.

• Worked with health plans and physician-hospital organizations to evaluate practitioners' efficiency and quality of care, including Allina Medica, Humana Health Plans, Harvard Pilgrim Health Plan, UniHealth America, and Blue Cross/Blue Shield.

• Reviewed cost and utilization management vendor contracts to ensure appropriate transfer of legal risk from employers to vendors, documentation of processes for monitoring program quality and service delivery, wording of risk-sharing agreements between vendor and employer, and contract termination clauses.

• Experienced in the field of group benefits as a practice leader and consultant at two leading employee benefits consulting firms.

• Performed speaking engagements for trade organizations, and published articles on cost and utilization management topics.

• Obtained from the University of California, Los Angeles, a Ph.D. in Health Planning and Policy, and a Masters in Public Health in infectious disease epidemiology--providing a strong clinical, statistical, and methodological background.

Represented Industries and Organizations

Copyright © 2009 Cave Consulting Group, All Rights Reserved