Medicare Direct Contracting

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The Medicare Direct Contracting (MDC) program is an unique opportunity for:

  • Existing Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs)
  • Next Generation ACOs (NextGen ACOs)
  • Medical groups participating in the CPC+ program
  • Provider or payor organizations that have experience serving Medicare fee-for-service (FFS)
  • Provider or payor organizations with limited Medicare FFS experience
  • Provider or payor organizations, including DSNP plans and PACE programs, with experience serving high needs Medicare patients including dual eligible patients

Organizations considering Medicare Direct Contracting may wish to grow or consolidate market share, enter into Medicare fee for service or leverage Medicare fee for service benefits coordination with an existing Medicaid managed care membership.

While Medicare Direct Contracting presents great opportunities, it is not the right decision for all organizations. An adequate level of readiness and risk tolerance; careful assessment, planning and execution are required to be successful under this program.

For those who are considering applying or who have applied, COPE Health Solutions can help you:

  • Determine how Medicare Direct Contracting can be leveraged and integrated with other payor strategies such as, self-insured employee health plan, Medicare Advantage, Medicaid managed care, direct to employer, commercial HMO and commercial PPO as part of your overall value-based payment roadmap
  • Perform a clear readiness assessment and identify ways to bridge gaps around requirements, such as (but not limited to):
    • Financial: Capital and reserves requirements, as well as break-even pro forma analysis to help inform go-no-go for execution of MDC agreement with CMS
    • Legal: State licensure, compliance, program integrity and new entity or governance structure,
    • Network Adequacy: High performing integrated network coordinating care amongst primary care, specialists, hospitals, post-acute, home and community based providers.
    • Infrastructure capabilities: MSO build or buy, IT, care management, financial management, provider and member engagement, performance management
    • Care Model: Delivery of services in and across each setting and by condition; and journey through continuum
    • Key Performance Indicators (KPIs): Ability to collect and analyze KPIs around member experience, provider satisfaction, and quality performance
  • Prepare and support your application for Medicare Direct Contracting (application deadline for Implementation Period (IP) 2020 is due February 25, 2020, and the application for Performance Year (PY) 2021 (5 year performance period is due Spring 2020 TBD)
  • Identify and implement initiatives to ensure success under Medicare Direct Contracting
  • Bring to bear our Analytics for Risk Contracting (ARC) platform and engage with you in an aligned gainshare model to ensure your success in Medicare Direct Contracting and other value based payment lines of business

As a national consulting firm born out of Southern California, home to some of the most successful capitated organizations in the country, COPE Health Solutions’ team of leading value-based payment experts have firsthand experience in managed care and capitation to enable your success with Medicare Direct Contracting.

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