Health Network One
The Solution for Rising Healthcare Costs and Denial Rates

When managed care organizations (MCO) aim to improve care for their members, they want their providers to focus on patients’ needs, while maintaining an appropriate cost of care. Yet when it comes to outpatient therapy, this is often easier said than done due to a significant increase in overutilization. With higher visit volumes and lower costs per visit compared to most other clinical disciplines, outpatient therapy (physical, speech, and occupational therapy) is difficult and costly to manage, which drives costs even higher, prompting vendors to handle cost containment through denials.

In this situation, health plans face the double problem of having cost of care issues along with dissatisfied healthcare providers and patients. Offloading these issues to traditional utilization management vendors rarely helps. Most of these organizations work on a fee-for-service basis and don’t have actual therapists in-house, relying instead on the checklists and denials that MCOs are trying to avoid.

With 25 licensed therapists in-house, Health Network One flips this situation on its head, absorbing 100 percent of the medical cost, risk, and reimbursing providers with a severity-adjusted fixed payment determined during peer-to-peer consultations.

“We are a category of one,” says Adam Kustin, VP of marketing & business development at Health Network One. “You won’t find another organization that does what we do specifically in outpatient therapy, which is to take full risk, have this comprehensive delegation, and a utilization management team uniquely staffed to support outpatient therapy.”

Headquartered in Fort Lauderdale, Florida, Health Network One works with more than 20 health plans, covering five million lives.

The company also manages podiatry, dermatology, gastroenterology, urology, and ophthalmology networks, but outpatient therapy is its flagship network.

Recognizing that every health plan is different, Health Network One begins every health plan engagement by discovering the current cost per therapy case across each therapy discipline and paediatric and adult age groups. The company’s business intelligence team examines historical claims data to define what will be covered under its capitated agreement with the managed care plans.

This tailored approach results in a weighted average cost per case, which is converted into per member per month (PMPM) rate and becomes the foundation of the risk deal with the health plan. Health Network One offers MCOs a capitated payment, which includes 100 percent of the medical and administrative costs while erasing administrative burden and reducing medical costs by as much as 20 percent. More importantly, the company is able to decrease the claim denial rate to less than 1.0 percent, providing peace of mind to providers that they will be able to render care, as well as to members that they will have immediate access to care.

Health Network One takes over four of the most important pain points of MCOs and operates as an end-to-end shop, providing for network development and management, provider credentialing, claims processing, and utilization management. “So really, it is just like, ‘Praise the Lord,’ the health plan can now hand off this part of their business with rising costs to us who are expert at it,” says Dr. Mary McCluskey, chief medical officer at Health Network One.

The company leverages its in-house built GDS system to offer self-service to providers while generating all required reporting to the MCOs. The system provides high visibility and supports the achievement of key performance metrics, such as encounter acceptance rate, reaching as high as 99.7 percent.

As expected from its name, Health Network One is all about the provider network, operating under the principle of “providers first.” There are no other vendors in outpatient therapy whose staff visits every therapist in their network at least three times a year. And when the company onboards a new client, it always offers participation to all existing providers of the health plan, which results in the expansion of the incumbent network by 3 to 4 times in just two or three years.

Health Network One considers providers as partners and prides itself on never being terminated by a client. “We have excellent relationships, some of which are as old as our organization, and the only way they could exist for that long is if we provide tangible, material value, year after year. And we are very hands-on, 360 degrees,” says Kustin.