Humana – Comprehensive Contracting and Network Management
Comprehensive provider network built across Nevada and Hawaii markets.
Hospital network ensuring extensive coverage and accessibility for Humana members.
Nevada and Hawaii — managing Medicare Advantage and Commercial Plans across all products.
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
Diverse Contracting
The project included contracting across all service verticals, encompassing hospitals, post-acute care facilities, physicians, Ambulatory Surgical Centers (ASCs), and more.
Expansive Network Management
Successfully built a network comprising 4,156 providers and 38 hospitals, ensuring extensive coverage and accessibility.
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).
Risk Management
Focused on risk-based contracts, managing complex arrangements like global risk contracts and dual/slip risk models.
Delegation of Functions
Delegated key functions to Independent Physician Associations (IPAs), optimizing the network management process.
Results
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.