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ACO Development

ACO Development

Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other healthcare providers who come together voluntarily to give coordinated, high-quality care to the Medicare patients they serve. Coordinated care helps ensure that patients, especially the chronically ill, get the right care at the right time to avoid unnecessary duplication of services and prevent medical errors. When an ACO succeeds in delivering high-quality care and spending healthcare dollars more wisely, it will share the savings it achieves for the Medicare program.

Given the complexity of the transition to managing risk, launching an ACO or a CIN requires an ongoing effort to achieve high-performing operational status. This effort unfolds in five overlapping stages lasting up to eight years. Health systems should use the following guide to ensure their strategies are on track and achieve the intended results.

  1. Developing the value-based strategy
  2. Forming the ACO/CIN
  3. Generating initial cost savings and quality improvements
  4. Managing the transition to risk
  5. Performing as a risk manager

Developing the Value-based Strategy

Organizations too often underestimate the importance of this essential first stage, developing a clearly defined, fully fleshed out strategy with appropriate benchmarks and a firm organizational consensus. Organizations should resist the urge to advance incrementally, thinking they can best move toward taking on risks by first gaining some experience and seeing how it relates to goals. Such an approach often results in the organization assuming risk before it is fully prepared to manage it. Instead, the focus should be on developing a plan that documents clear competency requirements, including the agreement on clinical governance, network design, care model design, goals for consumer experience, technology and analytics, and the financial model.

Forming the ACO/CIN

The costs of creating an ACO/CIN are likely to be minimal and incremental initially, relative to the organization’s top line. Much of the costs will involve reallocating staff, thus requiring no significant net new investment. In this stage, the organization should forge new connections among its clinical, financial and revenue cycle teams to identify issues around documentation or gaps in care.

In some cases, existing FFS infrastructure and revenue cycle management resources may provide the foundation for the value-based contracting and population health finances analytic team. The organization also may consider hiring an individual with health plan experience to start a team focused on analyzing and evaluating insurance impacts and value metrics. To keep health plan partners “honest,” the ACO/CIN will require actuarial capabilities to ensure targets for the cost of care and administrative allocations are appropriate. Initially, the organization may want to engage a third party for this purpose, but the goal should be to bring this capability in-house.

Health systems have tended to sponsor ACOs led by primary care physicians. Still, as they have taken on bundled payments for specialty care, such as end-stage renal disease, they are increasingly developing specialty ACO models. As the clinical networks mature, providers will add high-value primary care and specialist practices and more efficient post-acute care sites. Thus, optimizing and refining the clinical network will be an ongoing activity in an ACO’s development journey.

Generating Initial Cost Savings and Quality Improvements

At this stage, health systems begin implementing ACO/CIN programs to reduce costs. Such programs will require specific, measurable targets backed by performance reporting systems, with aligned incentives to ensure management is motivated to achieve results. To meet the targets, organizations must move their revenue capture teams from the back office and train them with new skills in value-based forecasting that can help them both optimize financial performance and communicate more effectively with clinical leaders. At this stage, the health system’s investment in episode analytical capabilities plays a critical role in driving cost savings and quality improvements.

If a health system’s strategy includes participation in bundled payments (e.g., focused on hip and knee replacement, diabetes or maternity care), the organization also will require dedicated teams of specialists around the specialty procedures. Targeting and establishing clinical guidelines for high-risk patients is an early priority, with the addition of low-cost sites of care in the clinical network and the development of patient portals for messaging and transmitting electronic health record (EHR) data.

Managing the Transition To Risk

Most value-based contracts are based on a plan to reduce costs by eliminating inappropriate utilization, lowering prices, and increasing market share by enhancing value to the consumer and reducing out-of-network referrals for care. As a result, ACOs and CINs, except for a handful of established, well-integrated medical groups in favorable markets such as South Florida, should expect to invest for several years before seeing a sustained reduction in the cost of care.

Performing As a Risk Manager

This stage involves an ongoing focus on continuous performance improvement and geographic expansion to include additional populations. It will require developing a new level of data sharing and collaboration among physicians and other clinicians to obtain optimum quality and financial results.

BPO - Business Process Outsourcing Services

BPO – Business Process Outsourcing Services

For the healthcare industry, the digital economy demands that organizations run better. The challenges include innovating, providing effective member-friendly services, streamlining and automating processes, containing costs, and increasing membership.

Technology can go a long way to help businesses achieve these goals. But taking it the rest of the way requires deep expertise in both healthcare and technology, along with mature services that deliver on their promises. Our integrated, end-to-end BPS solutions help your organization:

  • Improve processes, increase efficiency and reduce costs.
  • Innovate and compete more effectively.
  • Grow and retain membership, boost profitability and drive revenue growth.

Care & Quality Management

Care & Quality Management

Qualexa has a highly trained and knowledgeable team of Medical Professionals.
We are skilled in providing Care, and Quality Management delegated services in:

    • Utilization Management
    • Case Management
    • Disease Management
    • Quality Management


Contract Management

Contract Management

Payer &  provider and administration contract negotiation.

Contract negotiations are critical to the healthcare system. Qualexa’s team of professionals know how to analyze, initiate, and compare contracts to negotiate the best rates for your organization.

Our team makes it look easy, but negotiations can be intense and time consuming. Our contract management services are designed to remove annoyances caused by endless paperwork and applications.

We follow payor contracts from initiation to execution ensuring contracts are active, include all products, and providers are successfully linked to them.


Credentialing Administration & Management

The Qualexa team gives you peace of mind to focus on the safety and wellness of your patients by using its extensive experience and expertise to deliver highly responsive, accurate and cost-effective credentialing services. Qualexa Healthcare understands Credentialing and Contracting can be incredibly challenging and time-consuming for providers and new organizations. We manage all aspects of intricate credentialing, provider enrollment, primary source verification and more as we are an extension to Human Resources, Credentialing Departments and Medical Staff Offices.

Qualexa is your one-stop shop for a full spectrum of Credentialing Services, whether you are a solo independent practice or a National Health Care Delivery System.

Primary Source Verifications (PSV) for:

  • State Medical License
  • Controlled Dangerous Substance License (CDS)
  • Drug Enforcement Agency (DEA)
  • Board Certifications
  • Medical & Professional Education
  • Internship, Residency, Fellowship
  • Hospital Affiliations
  • Work History
  • Malpractice & Claims History
  • Ongoing License Sanction Monitoring
  • Medicaid & Medicare Sanction Monitoring
  • National Practitioner Data Bank (NPDB)
  • Council for Affordable Quality Healthcare (CAQH)
    • Initial
    • Maintenance and Updates
  • National Provider Identifier (NPI) Registration
    • Initial Registration
    • Maintenance and Updates

Contract Management & Provider Enrollment

It is essential to understand that the process of Credentialing and Contracting requires time, which can take four to six months to complete.
Few instances may shorten this time, but not often. Our team communicates with payers regularly confirming Credentialing is actively
taking place, maintained and current. Additionally, Credentials need to be reviewed and updated for contract compliance and privileging purposes.

Completion and submission of Provider Enrollment Applications with:

  • Commercial – Group and Individual
  • Medicaid and Medicare – Group and Individual
  • Medicare and Medicaid Revalidations
  • Payer Follow Up
  • Payer Contracts

Hospital Privileges

We can also provide Contract Management Services for all of your personnel.

Eligibility & Benefits Administration

Eligibility & Benefits Administration

Benefits and Claims Administration

  • Comprehensive Insurance and Managed Care Benefits and Contract Management
  • End-to-end Claims Cycle Processing and Adjudication
  • MSO/Claim administration
  • TPA Services

Healthcare Consulting

Healthcare Consulting

Transform Care with Valued Experience

Healthcare organizations can manage, optimize and transform their businesses to new, efficient business models with our consulting expertise.



State-of-the-Art Web-based Services

We utilize and incorporate the latest and most efficient technologies, which allows our business partners to obtain superior value and efficiencies through Qualexa’s service offerings.

TPA Services

TPA Services

Qualexa Services offers Third Party Administrator services, Claims Management, Managed Care and Risk Control solutions for its clients.

Claims Management

Qualexa strives to offer an integrated approach to claims management that will shorten claim duration, reduce overall claim costs, and ensure that beneficiary members receive the medical care they need to return to full health. We assess and counteract issues that delay claim closure through innovative technologies and a dedicated plan of action.

Qualexa TPA Services

Qualexa Services offers Third Party Administrator services, Claims Management, Managed Care and Risk Control solutions for its clients.

Qualexa strives to offer an integrated approach to claims management that will shorten claim duration, reduce overall claim costs and ensure that beneficiary members receive the medical care they need to return to full health. We assess and counteract issues that delay claim closure through innovative technologies and a dedicated plan of action.

Value-Based Care

  • Lower Costs
  • Better Care

Value-based payment can be a winning proposition so long as an organization has all the right pieces in place.

In the new era of value-based payment contracts, health systems will require a business and clinical model designed to help them assume increased risk. If value-based payment contracts with a health system’s sponsored Accountable Care Organization (ACO), our Clinically Integrated Network (CIN) is to be more than simply the next incarnation of pay-for-performance, they must lay the groundwork for a comprehensive population health management strategy, with all the pieces in place to manage the cost of care effectively.

Balance the use of traditional and new metrics.

The challenge for most health systems pursuing the value-based payment model is that they must do so while continuing to operate in a fee-for-service (FFS) world. That means they must continue using traditional FFS metrics focused mainly on volume while also developing new metrics and skill sets, such as:

  • Analyzing measures such as episodes of care for chronic conditions, utilization rates and practice pattern variations, deviations from care pathways and errors in outcomes reporting.
  • Becoming proficient in benefit design, product pricing and curation of care networks.
  • Understanding how the benefit design and payment rate changes described in the contracts will affect utilization rates and financial performance.

Vendor Management

Vendor Management

Qualexa provides Vendor Administrative Management support to our business partners, giving them peace of mind knowing that the various vendors and suppliers they utilize are managed consistently, effectively, and efficiently. Qualexa also offers economies of scale with Co-Op Group Purchasing.