Introduction

The collaboration with Humana offered an invaluable perspective on the health insurance industry, enhancing our understanding of payer dynamics. This case study outlines our comprehensive approach to contracting and network management in the Nevada and Hawaii markets, underpinning the success that Carenodes and its customers continue to enjoy.

Project Overview

Project Title: Comprehensive Contracting and Network Management with Humana

Scope: As the head of Contracting for Nevada and Hawaii markets, the project involved handling Medicare Advantage and Commercial Plans across all products. It included managing risk-based contracts such as IPA, global risk, and dual/slip risk, along with delegating functions to IPAs.

Solutions and Implementation

The project's success hinged on a multifaceted approach, encompassing various aspects of healthcare contracting and network management:

1. Diverse Contracting: The project included contracting across all service verticals, encompassing hospitals, post-acute care facilities, physicians, Ambulatory Surgical Centers (ASCs), and more.

2. Expansive Network Management: Successfully built a network comprising 4,156 providers and 38 hospitals, ensuring extensive coverage and accessibility.

3. Innovative Contract Models: Implemented a variety of contract models, including Fee-For-Service (FFS), case rates, bundles, shared-savings, Diagnosis-Related Groups (DRGs), Ambulatory Payment Classifications (APCs), and Average Wholesale Prices (AWPs).

4. Risk Management: Focused on risk-based contracts, managing complex arrangements like global risk contracts and dual/slip risk models.

5. Delegation of Functions: Delegated key functions to Independent Physician Associations (IPAs), optimizing the network management process.

Results

The partnership with Humana in these markets led to notable achievements:

• Robust Provider Network: Established a comprehensive network, significantly enhancing the accessibility and quality of healthcare services in Nevada and Hawaii.

• Diverse Contracting Models: Successfully managed a variety of contract types, demonstrating versatility and adaptability in contracting practices.

• Strategic Payer Relationships: Developed and maintained strong payer relationships, a crucial factor in the success of healthcare providers.

Conclusion

This collaboration highlights Carenodes' expertise in navigating the complexities of healthcare contracting and network management. Our experience with Humana has been instrumental in shaping the strategies that benefit our customers today. The success in the Nevada and Hawaii markets is a testament to our ability to manage diverse healthcare networks and contract models effectively, proving our commitment to enhancing healthcare delivery and payer-provider relationships.

Note: This case study is for informational purposes and reflects the project as of the date of publication.