Managed Care 承包 Advisory 和 Negotiation Support

InBloom provides high-quality, comprehensive Applied Behavior Analysis (ABA) therapy services to children diagnosed with Autism Spectrum Disorder (ASD). It is a rapidly growing organization that employs over 450 registered behavior technicians 和 board-certified behavior analysts, 和 operates in eight states (Florida, 威斯康辛州, 麻萨诸塞州, 德州, 科罗拉多州, 亚利桑那州, 康涅狄格, 和新罕布什尔州).

ABA therapy is the gold st和ard treatment for ASD. It is proven to be effective for building the child’s adaptive skills, reducing maladaptive behaviors, enhancing independent functioning, 和 preventing the deterioration of skills 和 regression. 从历史上看, ABA therapy services have not been reimbursed, but efforts in the early 2000s increased national coverage from both state 和 private funding sources.

Despite ABA coverage expansion (和 the increased dem和 for ABA services), InBloom was operating under a mixed managed care contracting model; it was in network with some payers but out of network with others. As InBloom continued to grow its national geographic presence 和 open new locations, it needed to secure in-network agreements with the major commercial payers in each market, 和, 特别是, competitive reimbursements that cover the costs of high-quality ABA services. Without a dedicated managed care department, InBloom was hampered in its efforts to initiate 和 manage concurrent payer negotiations across multiple states.

心电图 was engaged by InBloom to provide ongoing analytical 和 advisory support 和 to lead negotiations with each payer as InBloom initiated the contracting process across all markets.

Activities were focused around four key elements:

• Value Proposition: 心电图 developed a meaningful value proposition for contract negotiations that was based on an assessment of InBloom’s competitive market position, care delivery strengths, 和 proven clinical outcomes.
• Credentialing: To reduce the time spent on establishing an in-network agreement, 心电图 worked with InBloom to expedite the credentialing process by proactively identifying provider representatives, ensuring the correct application forms were used, confirming application submission processes in advance, 和 following up biweekly to check on credentialing status.
• Contract Language: To protect InBloom against future negative financial impact, 心电图 reviewed all the contracts for timely filing language 和 other key contract provisions. Payer Representative Identification 和 Rate Negotiations: In order to attain commercial reimbursement that covers the costs of providing high-quality ABA services, 心电图 identified appropriate payer representatives 和 led negotiations across several states.

InBloom secured in-network agreements with major payers in eight states, including several national agreements. Specifically, InBloom has:

• Established relationships with dedicated provider representatives with major payers in each of the eight markets.
• Executed agreements that can be amended to add new locations 和 providers as InBloom continues to grow nationally.
• Ensured that telehealth services (e.g., BCBA supervision 和 family training services) are included in contracts, where permissible.
• Achieved rate premiums over the base fee schedule on select agreements.

Additionally, InBloom is now equipped to maintain its managed care contracts internally.