​ According to AHCA/NCAL, a provider-owned network may have two tiers: 1) the Messenger Model and 2) Clinical and/or Financial Integration.

A Messenger Model allows the network to serve, as the name suggests, as a messenger to deliver a contract and present pay-for-performance (P4P) opportunities for each provider owner to either accept or decline.

Messenger Models are not allowed to negotiate rates. An Integrated Network may negotiate rates and is considered integrated by meeting additional quality, clinical, and cost factors. This has allowed networks to start operations quickly under a Messenger Model and move to develop a Clinically Integrated Model as more is learned about the factors that will best assist providers in tackling quality initiatives.

AHCA/NCAL said in order for its network model to stand apart and offer more value than the existing Messenger Model networks, it will require member providers to measure quality under both of the tiers. Providers will define a set of quality measures, agree to monitor these measures, and create benchmarks to present to MCOs.

MCOs traditionally focus on Medicare’s 5-Star measures, so the network’s quality information will set them apart from other providers and drive MCOs’ understanding and investment in meaningful quality measures. The network’s quality measures may also be used to negotiate and monitor P4P contracts and design new care protocols to better manage specific populations, such as residents dually eligible for Medicaid and Medicare who often have multiple chronic conditions and are living long term in skilled nursing facilities.

Provider-Owned Network Benefits and Services

As payers shift to value-based payments, approaching them for contracts as a network of provider owners is crucial, Colgan said. Without a network, individual providers may not have the volume of residents in each payer’s plan that is necessary to collaborate on P4P or at-risk agreements.
In addition to quality improvement, other benefits include:

Access to Payers and Contract Return on Investment

• Inclusion in more payer networks because payers prefer to work with single entities.
• Better terms due to the benefits of professional managed care staff and their understanding of state and national payer contracting.

Administrative/Credentialing Support

• Reduces administrative costs for documentation collection and submission to multiple health plans, by submitting to one entity (the network), allowing staff time for residents.
• Monitors contract terms and notices that may require other action to stay in-network.

Claims, Revenue Cycle, and Systemic 

• Payer Issue Solutions
• Reduces cost of claim issue resolution by providing a process and relationship with payers for escalating and resolving claims issues and identifying systemic issues.

Strategy and Understanding

• Ensures providers build new contracts focused on value-based reimbursement and leverages AHCA/NCAL expertise in moving to Clinical Integration.