Author: LBodnarchuk

The Affordable Care Act (ACA) — also known as “Obamacare” — is an inclusive healthcare law that aims to make healthcare insurance available to more people. It does this by lowering healthcare costs and mandating several requirements to ensure the plans are inclusive and accessible.

More Americans have enrolled for healthcare through the ACA than ever before — even the White House addressed the record ACA enrollment numbers. An ACA plan is a roadmap for your company to create and offer an affordable insurance plan with adequate coverage. ACA plans are crucial for the individuals who enroll, the healthcare insurance providers and the industry. Creating ACA plans diversifies your organization and lets you enjoy business growth and expansion.

Most importantly, understanding the complex and evolving regulations under the ACA is critical to ensure your plan is compliant.  The ACA requires all health plans in the marketplace to offer ACA-compliant programs that meet specific requirements. Of course, creating comprehensive plans that suit your business model is a top priority and balancing affordability and coverage is imperative. This guide outlines the requirements for an ACA-compliant program and how to launch your plan to cover costs and coverage.

What Impact Does ACA Have on Healthcare?

The ACA has had a positive impact on the health sector. The two main benefits of ACA are that it is inclusive and accessible. More Americans have healthcare today than ever before due to the affordability of these Plans for many individuals.

Additional benefits include:

• Comprehensive Provider Networks that must meet federal and state adequacy standards.
• Under the ACA, health insurance providers can’t deny coverage due to a preexisting health problem.
• The ACA prohibits health insurance providers from charging higher premiums based on gender, pre-existing conditions and other factors.
• All ACA plans must cover preventative services.
• Affordable access to prescription drugs.

As the ACA marketplace continues to evolve, there are still opportunity areas:

• Not everyone qualifies for ACA subsidies, so many Americans still find healthcare unaffordable.
• In areas with several issuers and product offerings, individuals can struggle to compare plans and navigate enrollment windows.

While these pros and cons affect individuals more than they do your business, it’s essential to be aware of them, as you can consider these points when creating a competitive ACA plan that meets consumer needs.

What You Require to Set Up an ACA-Compliant Health Plan

Creating a compliant health plan that follows the rules established by the ACA is essential:

• Cover essential health benefits: Cover the essential health benefits for your state to be ACA-compliant. These benefits include hospital stays, outpatient care, emergency care, maternity and newborn care, pediatric care, mental health coverage, prescription drugs, rehab services, lab resources and accessible options for preventive care.
• Rate review requirements: Comply with all state and federal regulations when developing and adjusting rates during annual review.
• Cap out-of-pocket expenses: To have an ACA-compliant plan, you must limit out-of-pocket costs for covered services. The out-of-pocket limit doesn’t include monthly premiums, out-of-network care and services, spending on services not covered in the plan and costs that exceed the amount for a service that you, as the provider, charge. This limit is set by the state in which you operate.
• Reporting requirements: Comply with reporting requirements by always submitting the required data of your plans, including enrollment numbers, coverage costs and the number of denied claims.
• Network adequacy requirements: The provider networks you contract with must be able to meet your customers’ needs adequately. Look into your state requirements for adequacy, including qualitative and quantitative standards.

How to Launch ACA Plans That Balance Affordability and Coverage

The ACA plan you design will meet certain benchmark standards but will also have elements unique to your organization and the portfolio you are building for target and expected populations. These general steps serve as an excellent springboard for launching your plans to make ACA more affordable:

Create an Outline and Goals

Develop a plan that outlines your goals and the strategies you can implement to achieve your objectives. ACA plans can be standardized, so finding various ways to stand out in the market while remaining compliant is vital. You can accomplish this by considering your current and intended market, branding, pricing, provider networks and the plan’s overall design. You want to use your strengths to position yourself in the competitive health insurance market.

The planning stage may take several months of researching the market but it does pay off when you offer a plan customers will gravitate toward.

Get Your Licensure

You must get licensure for the state(s) you operate in. Dive straight into obtaining your licensure as soon as you start the planning phase, as obtaining licensure is a lengthy application process that can take months to finalize and can vary greatly depending on your state. Consider the fees involved so you may add that to your budget. Plan so that you have all the required documents to get your credentials and licensure without a hitch, including but not limited to:

• Your National Provider Identifier (NPI)
• Certificate of Authority
• Financial Documentation
• Organizational Structure
• Attestations

Establish Provider Networks

Establish contracts with reliable provider networks that meet state requirements and who you trust to meet your customers’ needs. Develop an established provider network over a few months as you recruit and negotiate the terms of each affiliation.

Design Products and Strategize Pricing

The most crucial step is creating products, services and pricing options that comply with ACA’s regulations. Collaboration is the key to ensuring you make the best outline for products and pricing. Bring your financial team on board, your customer services team, your design team and marketing as you brainstorm on implementing new products, tweaking existing services, determining enrollment strategies and developing premiums.

Explore strategies regarding health costs to develop a realistic plan for balancing affordability and coverage that benefits you and your customers.

Submit a Qualified Health Plan Application

This is a yearly process that all health plans must complete to offer plans in any state or federal ACA marketplace. The application process opens in April and is concluded in September each year. Applications include templates and documents that outline your plan’s product offerings, rates, benefits, network and other vital information.

Development Systems

Strategize your options as you design and implement the practical components of your ACA plans. Practical elements include promotions or hiring new staff, choosing the best technology systems to fit your plans, how you will execute claims processing and implementing compliance procedures.

Develop and Grow Your ACA Plans with ProspHire

Having an ACA-compliant plan in your portfolio is crucial and developing the best plan for your business is undoubtedly a top priority. At ProspHire, you have a professional and reliable consulting firm supporting healthcare organizations as you develop and expand your portfolio. Our professional team works alongside you to tailor your ACA plans to your organization while offering expert advice and meaningful strategies to execute successful plans. We also assist you with marketplace accreditation, vendor implementation and business growth. Contact us today to achieve your ACA plan goals and learn more about our ACA plan development and expansion services.

Linked sources:

1. https://www.whitehouse.gov/briefing-room/statements-releases/2023/01/25/statement-from-president-joe-biden-on-record-aca-enrollment-numbers/
2. https://www.ncsl.org/health/health-insurance-network-adequacy-requirements
3. https://archpublichealth.biomedcentral.com/articles/10.1186/s13690-021-00645-w
4. https://www.prosphire.com/blog/soaring-to-new-health-blog/
5. https://nap.nationalacademies.org/catalog/13234/essential-health-benefits-balancing-coverage-and-cost

Welcome to Season 1, Episode 6 of the Soaring to New Health Podcast.

This episode is The Stars are Aligned. We’re diving deep into the world of healthcare and performance improvement. Medicare Stars and its far-reaching implications – what it is, why it’s important for health plans and members, common challenges and successful strategies. Dan Weaver, Senior VP of Stars and Quality at Zing Health and Andrew Bell, Stars Performance Leader at ProspHire.

Medicare Star Ratings are a way to measure and compare the quality and performance of Medicare Advantage and Prescription Drug Plans. The ratings are based on a scale of one to five stars, with five being the best, and they reflect various aspects of the plans such as customer service, patient outcomes, preventive care and benefits. Medicare beneficiaries can use the ratings as a guide when choosing a plan that suits their needs.

In Medicare Stars Plans, there are three categories based on the quality ratings on the plans: plans that have lost their rating, plans that have maintained their rating and well-positioned plans. For those that have lost their rating, recommended strategies include both foundational elements if identifying and addressing the deficiencies and implementing robust processes for advanced analytical components.

Dan Weaver says preparedness is the key. Gather your resources to collaborate and review and compare interpretations, seek outside expertise to help you align on steps that focus on sustainable improvements in quality and continuously monitoring and improving performance. The challenges to successful Star ratings are going to be different for every plan – from resource constraints to provider network challenges to data accuracy and documentation. Addressing these requires a comprehensive and targeted approach, including strategic planning, investment in resources, collaboration with stakeholders and a commitment to continuous quality improvement.

It’s crucial to understand that, at any given moment, your plan is influenced by activities spanning three distinct Star years. Approximately a year before the service dates, HOS surveys are conducted. These service dates take place within a calendar year. The subsequent year involves operational impacts, encompassing CAHPS survey, TTY foreign language testing and other pertinent assessments.

The Medicare Stars Program is highly regulated by CMS and it is common to see modifications to the program, be it measures added or removed, calculation adjustments or weighting changes. Looking ahead, CMS proposed to reduce the weight of patient experience/complaints and access measures from 4x to 2x for the 2026 Star Ratings.

For the more in-depth discussion on Stars Performance Improvement download the Soaring to New Health podcast, The Stars are Aligned, where you find your podcasts.

Dental Practice Management enables Dental Service Organizations (DSOs) and dental providers to reach their full potential. With Dental Practice Management, you can streamline administrative processes to benefit employees and patients through innovative technologies and strategies. It also makes your business resilient, competitive and scalable, even in an uncertain market.

Building an effective Dental Practice Management system requires a good understanding of the industry and what it takes to optimize operations. Below, we discuss the basics of Dental Practice Management, including its benefits and some best practices for developing a functional system.

Dental Practice Management Explained

Dental Practice Management is a system that identifies lapses in operations and implements strategies to close those gaps. It’s a tailored process that helps dental practitioners and administrators streamline operations. At ProspHire, our Dental Practice Management experts help create scalable businesses by closely examining the operations and providing solutions to make them more efficient in the provision of quality patient care.

Effective Dental Practice Management programs are simple yet comprehensive. They streamline workflow with organized systems and technology and provide growth opportunities to create a well-managed and effective dental practice that can succeed.

What Are the Benefits of Dental Practice Management?

Dental Practice Management offers many benefits. Here are some examples:

Streamlines Operations

Dental Practice Management allows you to implement efficient and standardized processes for your practice. Good organizational planning and technological solutions optimize workflow. As a result, you can improve collaboration and communication, reduce costs and better comply with industry standards and regulations.

Streamlined operations improve the ability of a DSO to work effectively with its affiliated offices via alignment on systems, protocols and centralized and localized resources. Structure amplifies the ability of the DSO to provide comprehensive support to practices ultimately improving opportunity for positive financial and treatment outcomes.   

Simplifies Staff Management

One of the first steps to creating an efficient practice is having a well-organized and functioning staff. Practice Management enables you to assess your current staff’s strengths and provide the tools to help them grow.

For example, it creates a platform where you can monitor each person’s input, letting you know how to tailor your training initiatives. It also considers strategies to encourage your employees to accept new changes, considering factors like age differences and exposure to modern technology.

Dental Practice Management can also help you set employment standards, assign roles, improve communication, collaboration and teamwork and implement proper hiring systems.

Improves Talent Acquisition

Onboarding new talent is as important as managing your existing team. Talent acquisition should go beyond getting academically and professionally qualified recruits, as you also want to find employees who fit into your practice’s culture and mission.

Dental Practical Management leverages modern tools to identify the best candidates for your practice. It also helps you establish recruiting systems capable of examining behavioral traits and assessing how they match your demands.

Reduces Errors

Eliminating errors is fundamental for any healthcare practitioner and can save you time and money. Traditional dental practices often involve tedious administrative processes that can cause employees to lose focus and make errors, but you can fix that.

You can employ automated solutions to handle processes like billing and scheduling. Digital tools are highly accurate and can process large amounts of data, removing inconsistencies and creating reliable outcomes. As a result, you can free up your staff to focus on more in-depth, engaging tasks.

Optimizes Client Access

Your website and front office are the gateways to your dental practice and are where you first interact with patients. An effective Dental Practice Management system allows you to accommodate patients and make them feel at home, so you leave them with a positive initial experience every time.

A Practice Management system makes it simple for you to connect with patients. It focuses on aspects such as:

• Accessing preliminary information like contact information and areas of specialization
• Scheduling appointments
• Keeping records
• Communicating with clients regularly

Improves Overall Patient Experience

Dental Practice Management helps you create lasting client relationships. Simple things like knowing clients by name or face and streamlining their appointments can make a difference. With a streamlined workflow through Dental Practice Management, you can build a better experience in the office and during virtual consultations.

Drives Revenue and Growth

One of the main goals of a management system is to drive growth, which is usually a natural consequence of proper staff and financial management, process automation and client satisfaction. Dental Practice Management lets you build a scalable enterprise capable of withstanding uncertainties. You can leverage data to make financial decisions and plan.

What Are Dental Practice Management Best Practices?

Building a resilient dental practice requires high operational efficiency. Here are six best practices to consider:

• Define your needs: Define what you need to grow your practice and build the system around that. Having a clear path helps you determine the most practical strategies.

• Leverage technology: Digital transformation is integral to all business operations today. Automate your processes, starting with the most basic functions. Use technology to streamline operations for both employees and patients.

• Listen to your staff: Your management strategies are most effective when every employee is onboard. Consider their concerns and develop solutions to help them perform optimally. Also, engage them in continuous training programs and set clear goals and expectations.

• Consider patient communication: Focus on making communication simple yet effective for patients. For example, if you notice many patients submit appointment requests through your website, consider implementing a chatbot to make that experience even better.

• Create flexible payment options: Never underestimate the convenience of having flexible financial options. Allow patients to select from various payment options like cash, credit cards and checks. Payment plans and financing are also effective solutions.

• Hire a consultant: Dental Practice Management consultants have the experience to examine your operations and execute solutions to help you grow your business. Choose a company that understands your industry and your business’s needs to make your investment worthwhile.

3 Tips to Consider When Choosing a Dental Practice Management Company

Here are some tips for choosing the best Dental Practice Management company for your establishment:

• Do your research: Ask colleagues for referrals and interview different companies before deciding. Also, establish criteria for the kind of professional you want to engage.

• Prioritize industry knowledge and experience: The best consultants have a wealth of experience that lets them evaluate different options. They can help you make effective decisions and provide personalized solutions.

• Consider customer relationships: It’s best to work with consultants interested in seeing your business thrive. Listen carefully and take notes of their responses when you ask questions. This way, you can gauge whether they seem to truly care about your success.

Choose ProspHire for Your Dental Practice Management

ProspHire assists DSOs and dental providers in developing innovative solutions to streamline operations and drive growth. Our expertise and quality services have won us several awards across the United States and we continue to serve clients with a supportive culture.

Contact us today to learn more. We’re ready to build a long-lasting relationship with you.

October is Breast Cancer Awareness Month, which serves as an important reminder to schedule regular wellness visits with your healthcare practitioner. According to the National Cancer Institute, one in eight women will develop breast cancer during their lifetimes¹. When we take a closer look and consider the demographic data surrounding breast cancer outcomes, worrying disparities emerge between rates of diagnosis and mortality between different groups.  

For example, while white women are more likely to be diagnosed with breast cancer, black women are more likely to die from the disease. Race and discrimination are an example of a social determinant of health (SDOH), which are the non-medical factors which influence health outcomes². We will further address race and other SDOH factors which contribute to disparities in health outcomes and assess ways these disparities can be addressed.  

Establishing the SDOH-Driven Disparities in Breast Cancer Outcomes  

When assessing causes of cancer, generally more attention is paid to genetics and individual health behaviors than SDOH influences. However, there is strong evidence that breast cancer outcomes are influenced by SDOH factors, which emphasizes the importance of at-risk groups obtaining regular breast cancer screenings from their doctor.  

Race has emerged as a main contributing SDOH factor to breast cancer health outcomes. White women are more likely than black women to be diagnosed with breast cancer, but black women are 40% more likely to die from the disease³. A research study conducted by the University of Illinois-Chicago concluded that social determinants of health are the roots of these racial disparities in breast cancer outcomes⁴. Specifically, the study cited neighborhood disadvantage and insurance status as contributors of 19% of this outcome disparity⁵. Addressing these barriers on a large scale will require wider public policy changes, but the key is to identify short-term interventions to fix such disparities.  

Lack of insurance is correlated with poorer health outcomes. There is evidence that state expansion of Medicaid enrollment contributes to improved breast cancer health outcomes. Women from economically disadvantaged backgrounds, who might normally avoid the doctor due to cost or burden of access, are able to obtain breast cancer screenings (mammography) through Medicaid. Prior to the Affordable Care Act, this is evidenced by overall higher rates of mammogram screenings in states which have expanded Medicaid⁶. For example, incidence rates of black women being diagnosed with breast cancer decreased from 24.6% to 21.6% in states which expanded access to Medicaid compared to states that did not expand access, which sit at about 27%⁷.   

Closing the Gap 

Consistently throughout this analysis, lack of health insurance access, for both the uninsured and underinsured, has emerged as a driving factor for disparities in breast cancer health outcomes. This is especially the case when a lack of insurance is coupled with socioeconomic disadvantage. Whether you are a health plan, accountable care organization or breast cancer awareness organization- what can be done to close this gap?  

Specialized health interventions are often the most effective short-term method to address SDOH-driven health disparities. For breast cancer, findings by the Community Preventative Services Task Force (CPSTF) recommend engaging community health workers (CHWs) to increase mammography screenings⁸. Often, there is a wedge driven between healthcare workers and the public which can be attributed to factors such as community mistrust or lack of health literacy. CHWs serve to bridge this gap, working in tandem with healthcare professionals or on their own. CHWs can assist in making screening services more accessible than a typical doctor’s visit, by assisting with interventions such as group education, 1-to-1 education, client reminders or newsletters⁹.  

How ProspHire Can Help 

ProspHire can assist in breast cancer screening adherence improvement strategies and community-based partnership development to support health plans engage members in preventive care. Our practitioners support the strategy and execution to drive improved outcomes for plan members with a focus on health equity. 

Welcome to Season 1, the Bonus Episode of the Soaring to New Health Podcast.  

This episode is Who the Health is ProspHire. Our hosts, Chris Miladinovich and Dan Crogan are talking with Lauren Miladinovich, CEO, Managing Principal and Co-founder of ProspHire about the history of the Firm, why the focus is 100% on healthcare and why relationships are the number one core value. 

Lauren and Chris started the Firm in 2015. Within a year they opened the first office space on the North Shore of the city of Pittsburgh. By year three they determined the focus to be 100% on healthcare, earned a woman in business certification and expanded the headquarters to a new location in the Pittsburgh Power Building in downtown Pittsburgh. As ProspHire was about to hit a milestone five-year anniversary in 2020, COVID cases spiked and we all found ourselves in the midst of a global pandemic. Small but mighty, ProspHire took an agile approach and adapted, pivoted and succeeded in a rapidly changing, ambiguous, turbulent environment. The leadership team is already looking forward to its 10-year anniversary in 2025. 

Coming up with a company name was not a priority at the time but ended up being a big deal.  

Chris had a few requirements: it had to be less than 2-syllables, the domain name had to be available and it had to be easy to say. ProspHire was derived from the first mission statement that ‘clients hire us to help them prosper’. Everyone in Chris’s inner circle said it was great but it didn’t do well when it hit the market. No one could pronounce it, understand what it was or what it meant. The few years that followed included a lot of marketing dollars to create over 1,000 alternative names… all rejected. To this day, they still have fun with mispronunciations. 

Before 2015, Lauren was leading large, complex project management engagements and Chris had experience in health and human services and the consulting industry. Together, they had a passion to do something that helped businesses that helped others. Focusing 100% on the healthcare industry was a natural fit. 

One of their favorite activities is the annual Prosper Together Day. The Firm’s charity of choice is the Boys and Girls Clubs and every year in Pittsburgh and now in Philadelphia the employees spend an entire day in interactive STEAM (Science, Technology, Engineering, Art and Math) activities that teach leadership and life skills, as well as played games with the children of the Clubs. Lauren and Chris’s pet pig Nola sparked the relationship with the Clubs. Nola had her own Facebook page and the Clubs had been following her story when they reached out to propose making her the celebrity for a new Kiss-a-Pig Fundraising Gala.  

For more on the history of ProspHire and why client relationships are so important, download the Soaring to New Health podcast, Who the Health is ProspHire, where you find your podcasts. 

Welcome to Season 1, Episode 5 of the Soaring to New Health Podcast.

This episode is The Glass is Half Healthy. We’re talking with Dan LaVallee, Senior Director of Social Impact from the Insurance Services Division at UPMC Health Plan along with Julie Evans, leader of ProspHire’s Social Determinants of Health (SDOH) service offering.

Social Determinants of Health are coming to the forefront of the healthcare industry for a lot of reasons – and one of those is health equity. Health equity is understanding that different individuals across the country have different health outcomes and a lot of that is determined by the zip code they live in. Part of SDOH is thinking about how we can focus our efforts on healthcare to address those specific needs and therefore address health equity as well. An example is if a child with asthma is growing up in a home with overcrowding and poor air circulation. The child will not be able to address their asthma needs without appropriate social determinants of healthcare in housing.

LaVallee says the Center for Social Impact wants to get ahead of scenarios where the population cannot access healthcare with prevention, support and listening to solutions from within those communities. Data shows that if you can find these members supportive housing for 10 months, it can change the trajectory of their healthcare. It takes a coordinated effort of community organizations that provide jobs, housing, benefits access and food programs to create a circle of member trust. The Center’s Cultivating Health for Success Program aims to get homeless Medicaid recipients in Allegheny County (and now Blair and Lawrence Counties) off the streets and into structured, long-term care by combining the resources of UPMC Health Plan and the housing-focused Community Human Services (CHS). Across the State of Pennsylvania, the Regional Accountable Health Council (RAHC) created forums for strategic health planning that provide a community-led approach to implement the planning and coordination of activities that address social determinants of health needs, reduce health disparities and promote health equity and value in health care.

At UPMC Health Plan, the Center for High Value Healthcare evaluates the impact of the programs supported by the Center for Social Impact, like the new Food is Medicine Program. They will help determine what works that is social impact related and then expand on that, all while seeking continual member feedback.

Evans talks about these types of programs helping Stars, HEDIS and CAHPS measures that tie back to the quality health incentives that are so important to health plans for their members. The investment into SDOH programs can show immediate return on investment. The impact of the pandemic is what really highlighted the needs of vulnerable individuals. Today we are seeing an influx of funding to support community-based organizations and health plans to address those needs but the concern is that as the public health emergency lifted the funds will dwindle and programs will not be sustained. That’s a huge barrier to housing and transportation challenges, which are being spotlighted right now. The future will include how to address these needs without funding.

At UPMC Health Plan’s Center for Social Impact, LaVallee says they are doing a good job of staying ahead of these challenges through investment and community partnerships and leveraging a model that can scale in one community and be replicated in others. There is no intention of slowing down.

For more on Social Determinants of Health, why they are important to measure and how they can play a role in more efficient care with better patient outcomes, download the Soaring to New Health podcast, The Glass is Half Healthy, where you find your podcasts.