Managed health care business management consulting, finance, development and health care financing administration services

Health care business management services

Building an effective team is key to the success of any business, especially the highly competitive, ever-changing world of health care management. Visit this section to learn more about our management-minded services, including:

• Corporate and Administrative Programs
• Utilization and Quality Management
• Medical Practice Management and Medical Service Organizations
• Benefit Programs
• Marketing and Sales Programs
• Reinsurance and Risk Management

Corporate and Administrative Programs

Re-engineering to fine tuning your company for efficiency and effectiveness, AMG will conduct a complete examination of your operations, financial structure and objectives. We can also focus on a single department or project of your choice.

AMG will conduct financial revenue and cost analysis, management assistance and reporting process improvement. Areas of focus include indemnifying opportunities and improving business and financial processes

Our professionals listen to you and your staff, then get them involved in the re-organization, thereby creating a process ownership from within.

Recruiting personnel is extremely time consuming. AMG will assist you in identifying key positions and train the staff for you.

Documentation and procedure manuals are one of the most neglected areas in many companies. AMG will take this burden and, while writing the documents, offer suggestions for a more efficient method for cost savings measures. All this will be achieved while maintaining a high level of customer service.

AMG will also review potential relationships with selected vendors and review contracts to identify potential problem areas. We assist you in the negotiations of the contracts and play the "bad guy" for you.

Through an operational analysis and restructuring program, AMG will assist you in achieving increased productivity and performance while benefiting from cost savings through information systems assessment, process improvement and performance measurement tracking.

AMG tailors solutions to fit your company’s specific needs. We address immediate issues as well as long-term strategies.

Today’s marketplace has become much more difficult to manage legally, financially and operationally. Today’s market is not the same as yesterdays. It has become very difficult to keep all departments and systems synchronized during these ever changing times. We can help you assess, manage and monitor these changes.

Law changes, regulatory environment and market demands have created a larger assumption of risk for the Payor and providers. AMG can assist you in streamlining the processing to lower costs while building a comprehensive reporting structure for monitoring. Critical areas to explore include:

• Corporate strategies and re-engineering
• Budgets and projections
• Cost reduction programs
• Project planning and implementation
• Procedure, policy and operational programs
• Automation, processing, and interface programs
• Corporate and fiduciary accounting
• Reinsurance treaty negotiation
• Processing and system interface procedures
• Quality Control Programs
• Premium billing and receivable
• Corporate accounts receivable and payable
• Administrator audits and review
• Underwriting and actuarial
• Compliance
• Internal and external financial, claims and providers audits
• All benefit processing functions

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Utilization and Quality Management

Utilization Management, Analysis and Review

Health care organizations are assuming greater amounts of financial risk in providing care for their covered lives. Information regarding utilization on multi-tiered levels are essential in real-time to manage the business.

A key element to maintaining a strong network is fair and effective utilization management and review. AMG strives to make the system as easy as possible for the providers and the patients while maintaining the financial integrity of the company.

AMG will assist you with your UM and UR program design, monitoring tools, staff training and reporting criteria. Additional areas to explore include:

• Utilization Management policies, procedures, and guidelines
• Pre-certification and referral programs
• Documentation and operational structure
• Treatment plan criteria and protocol programs
• Concurrent review programs
• Alternative care programs
• Case Management programs
• Risk Management
• Utilization Management committee development and training
• Provider practice patterns
• Outcome, audit and record assessment programs
• Utilization monitoring and analysis programs

Quality Assessment Programs

Quality and outcome measurements can be very difficult to assess. Regulatory requirements and consumer demands have created a major undertaking for your company. AMG has assisted many companies in identifying and developing quality assessment criteria and programs that work for your company while meeting the demands of the industry and legal rights of the physicians, providers and patients.

• Outcome management studies
• Enrollee and Provider assessment and survey programs
• Wellness, safety, and injury prevention programs
• Preventive care studies
• Credentialing and evaluation programs
• Committee structure development and education
• Grievance programs
• Enrollee education programs
• Algorithm criteria for hospital, ambulatory, medical and ancillary care
• Medical appropriateness studies and on-site review programs
• Internal audit programs
• Quality control and cost containment programs

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Medical Practice Management and Medical Service Organizations

AMG works with single office practitioners to large medical management service organizations. From start-up offices, reorganizations and increase business opportunities, AMG will identify your needs and implement a plan specific to you.

Before you enter into a contract with a Payor or provider network, AMG will review and negotiate the agreement to your best advantage. Many providers have entered into agreements that put the provider at risk not advantage to the provider. AMG will inform you of all positive and negative aspects of the contract for you to make a fully informed decision.

• Coding analysis
• Medical practice start-up, acquisitions, sales, and reorganizations
• Client base ratios and diversification
• Third-party payor negotiations and contracting
• Market strategies and planning
• Industrial contract analysis
• Efficiency and cost reduction evaluations
• Product negotiations
• Provider network negotiations and contracting
• Operational work flow analysis and development
• Complete medical practice management programs
• Automation and data processing evaluations
• Budgeting and forecasting
• Risk management
• Accounting programs: General ledger, accounts receivable, accounts payable, and payroll
• Tax planning and preparation
• Cash management
• Asset and liability management
• Work-out programs
• System analysis and integration
• Electronic data interchange (EDI)
• Government and payor audits

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Benefit Programs

Plan Design and Development

AMG’s experience in regulatory differences will assist you in plan development and compliance. From market analysis, benefit design, funding requirements and administration functions, AMG will make you operational.

AMG can assist in the development of new benefit plan designs, documentation and materials to help you hit the market more quickly.

Our actuarial professionals will assist you in rate development and capitation carve-outs.

If an E.R.I.S.A. plan needs to be developed, modified or updated, AMG can help you in all the areas necessary for an employee-friendly yet cost-effective program.

Product lines include: Commercial, Medicaid/Medical, Medicare, TriCare/Champus, E.R.I.S.A. and special market products.

Benefit programs include: medical, dental, optical, life, 401K, MSA, Section 125, supplemental, Medigap, cafeteria, carve-out, prescription drug and specialty programs.

• Product and market analysis
• Benefit plan design, review, and implementation
• Actuarial studies and forecasts
• Underwriting development and guidelines
• Compliance adherence
• Plan documents, policies, and enrollee summaries
• Enrollment materials and training

Benefit Processing Programs

Benefit processing has become a very complex part of the business. AMG will assist you in selecting a system or third-party vendor/administrator for this task.

If your company’s current systems are not adequate to fill today’s processing needs, AMG can evaluate your system to determine the deficiencies. AMG can work with your current staff and/or vendor to correct such deficiencies, or develop interface programs to accomplish the task(s).

If you are looking to purchase a system, AMG will evaluate the potential(s) system to make sure that the systems fit your needs and growth.

If your company does not want to process benefits, AMG can recommend alternative solutions and provide vendor performance reviews.

• Eligibility, enrollment and underwriting policies and procedures
• Eligibility and benefit verification
• Claims and Encounter adjudication and processing
• Complete benefit processing systems and programs
• Investigations, audits and reviews
• Benefit compliance
• Claim documentation
• Subrogation, liens and coordination of benefits
• Fraud Abuse investigation of providers/members
• Reinsurance audits and shock loss tracking
• Member and policy service
• Quote and sales tracking
• Billing and accounts receivable
• Payables: claims, commissions, etc.
• Specialist and ancillary referral tracking
• Pre-certification and inpatient tracking
• Concurrent review and case management
• Utilization management and analysis
• Quality Assessment
• Full accounting and reconciliation
• Third -party payor transition programs
• Systems interface
• ID card issuance and policy generation

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Marketing and Sales Programs

Marketing and sales for a new or mature market can be very difficult and consume large amounts of resources. AMG can assist you in your marketing and sales program to get your company going or revitalize your existing program.

• Full range of marketing products developed for Third-Party Payors and Provider Networks
• Market analysis, comparatives, and demographics
• Sales program development
• Marketing brochures and sales aids
• Commission development
• Product education programs and seminars
• Multi-structural benefit programs through joint Payor consolidation agreements
• Multi-level and divisional marketing programs
• Community based organizational programs
• MGA, Broker and agent negotiations and contracting

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Reinsurance and Risk Management

AMG has years of experience in evaluating the accuracy of reinsurance claims for both the claimant and payor. We can assist you in evaluating and obtaining reinsurance that is appropriate for your risk and cash flow needs.

• Research and acquisition
• Reporting, analysis and audit

For more information on how our health care business management and consulting services can improve your bottom line, contact Allied Management Group today.

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Managed health care business management consulting, finance,
development, and health care financing administration services.