Case Study 1:
A HMO, a Consulting Firm, and 6 IPAs Share Data through SmartCare®

A consulting firm with numerous provider organizations as clients negotiates contracts on their behalf with HMOs and insurance companies. As part of these contracts, certain financial incentives are incorporated which reward the doctors for performing more preventive and wellness procedures, such as retina exams for diabetics and Pap smears for post-menopausal women, as well as other incentives for controlling resource utilization.

The consulting firm negotiated such a contract for 6 IPAs, comprising over 2,000 doctors and 5 hospitals, with an HMO to provide care for 102,000 of its members. In addition to the reimbursement system in the contract, the HMO set aside a very large sum in a bonus plan if the IPAs could meet the preventive, wellness, and utilization targets.

The HMO began sending monthly files of professional, hospital, lab, and drug claims, along with membership eligibility files. It took less than 3 weeks for these files to be reconciled and successfully imported into SmartCare®. After each data load, cumulative year-to-date studies are created in SmartCare®, and a variety of provider tracking reports are run. This has continued for 3 years, now providing the consulting firm with the ability to compare practice patterns over a substantial period of time and better negotiate terms. The HMO is satisfied because it is now proven that these doctors provide excellent quality of care at reasonable costs.

In one situation, the HMO sent a letter to the consulting firm informing them that 24 of the 2,000 physicians were coding in ways significantly different than their peers, and would be removed in 30 days if these issues could not be addressed. Using SmartCare®, the consulting firm was able to review the coding patterns of all 24 physicians in less than 1 day. They then were able to show these doctors the data and suggest changes where necessary. None of the doctors were dropped by the HMO.

In 2002 the consulting firm concluded another similar arrangement, this time with a major insurance company for these same IPAs to provide care to over 100,000 of its members.