Health Plans & RBOs

Health plans and risk-bearing organizations (RBOs) face increasing pressure to effectively manage and administer complex, multifaceted risk pool agreements and respond to stakeholder requests for risk pool funding.

As the health care industry moves away from rewarding providers for volume and shifts to rewarding for value, organizations need to embrace this paradigm change and thoughtfully prepare for it. In the complicated managed care environment, the risk-based health care model continues to rise in popularity. The model has significantly evolved since its development more than 25 years ago, and many organizations engaged in risk contracting lack the industry-based expertise to support developments and effectively manage their membership.

Our professionals have roots in California, the epicenter for managed care and RBOs since they first rose to prominence. Immersed in risk-based health care for decades, our professionals understand how to make smart business decisions and find innovative solutions that drive growth and strengthen your bottom line.

How We Help

We can assist your organization with:

• Capitation reconciliation and eligibility and membership administration
• Claims audit and recovery and processing
• Contract analysis and negotiation
• Cost containment and revenue enhancement
• Development of dashboards and line of sight metrics driving clinical and operational excellence
• Governance development and enhancement
• IT compliance, strategy, development and integration
• Lean consulting
• Managed care system assessment and procurement
• Operational excellence, including assessments and recommendations
• Network optimization
• Process improvement implementation
• Provider risk analysis, contracting, and operational design
• Risk pool performance assessment and auditing  
• Service line enhancement
• Strategic planning and implementation
• Value-based infrastructure, including Medicare Access and CHIP Reauthorization Act (MACRA) and value-based revenue model readiness and gap analysis

Who We Serve

We work organizations of all sizes including:

• Accountable care organizations (ACOs)
• Coordinated care organizations (CCOs)
• Dental plans
• Exclusive provider organizations
• Insurance exchanges
• Independent practice associations (IPAs) and medical groups
• Knox-Keene plans
• Managed care and service organizations
• Medicaid health plans and Medicare advantage plans