...Within the walls of Amerigroup, the total claims that 30 employees process on a daily basis equals the total output of the company by all employees combined. Employees are required to process between 250 (7500) and 300 (9000) claims daily. Therefore, Amerigroup’s marginal product shows there is an increase or extra output added by hiring 12 additional employees to increase production. Unfortunately, the more employees added to the production cycle declines the per unit output of employees. What this entails is that every employee process nearly 250 claims daily and adding 12 more people increases productivity to average between 10,500 and 12,600 claims every day. Although the numbers look good there is a problem that may arise; the company may find themselves with limited equipment or other resources may become bottlenecked, and not to mention physical limitations if an employee becomes ill. This problem is called, diminishing marginal return resulting in employee work production to decline. In other words, marginal product will be positive, but declining, as the input increases McConnell, Brue, & Flynn, 2015). Therefore, as a manager one practical method to raise marginal product per employee and that will help Amerigroup begins with offering on-the-job education and training; doing so will increase not only employee productivity and income but improve profits for the company. The company may also rely on motivation tools such as rewards instead of hiring new employees...
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...Amerigroup’s PCMH Strategy • Our strategy is focused on transforming our delivery system and working more directly with providers of health care services to improve the quality and efficiency of the care delivered to Amerigroup members. • The core of this strategy is focused upon devoting resources to our primary care providers to assist them in becoming highly functioning patient-centered medical homes within an integrated delivery system • The foundation of this strategy starts with primary care providers and works through to the execution of the Patient Centered Medical Home (PCMH) concept. Building upon this foundation the strategy expands to specialists, hospitals, and ancillary providers of services to build a delivery system for Amerigroup . members that are aligned to produce better outcomes, higher quality, and lower costs. AmeriGroup Florida Amerigroup Florida, a health plan, works collaboratively with seven psychiatric hospitals to improve patients' transitions to outpatient care, with the goal of reducing readmissions. The plan's behavioral health manager meets quarterly with hospital leaders to review data on admissions and length of stay, discuss select cases of readmitted patients to determine how patient care could have been managed differently, and identify strategies to improve quality and reduce the risk of readmissions going forward. Strategies focus primarily on steps that can be taken in the inpatient setting to facilitate the provision of appropriate...
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...state. The organization has run into an issue within the customer service department with their overall quality scores for the Anthem/ Amerigroup plans across all states. Quality Score is a major part of what the HMO looks at to determine if the company is maintaining their agreement. Directors and Account Executives had monthly meetings to review guideline criteria, which now has turned into a weekly meeting discussion. For several months, the department has not been able to maintain their quality scores for hold times. With the increase in multiple factors like membership and eligibility issues, members and providers currently have an average wait time of an hour. The requirement that is agreed upon remained no more than ten mins. Anthem/ Amerigroup in one of our largest plans and losing this contract can cause considerable damage to the company’s revenue. If the contract terminates, the result could bring on termination of employment for many in all departments, termination of providers and potential closure, if the effect is that great. Currently, they are experiencing a high number of providers who are now refusing to see Molina member’s due to this inconvenience. With an increase of providers who are refusing to see members until the issue is resolve can impact about 120,000 people who are covered under the Anthem/ Amerigroup plans. To avoid this problem, HR will need to the help of human resource planning and organizational strategy to help formulate and strategies...
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...Introduction Fraud and Abuse in the U.S. healthcare system is a serious problem. Health care fraud and abuse is a national problem that affects all of us either directly or indirectly. National estimates project that billions of dollars are lost to health care fraud and abuse on an annual basis. These losses lead to increased health care costs and potential increased costs for coverage. Specifically, health care fraud is an intentional misrepresentation, deception, or intentional act of deceit for the purpose of receiving greater reimbursement. Health care abuse is reckless disregard or conduct that goes against and is inconsistent with acceptable business and/or medical practices resulting in greater reimbursement (BlueCross BlueShield of North Carolina, n.d.). It is not only criminals defrauding the government and healthcare system. There are hospitals doctors and pharmaceutical companies who try to cheat the system. The types of people who commit these crimes are varied, from the highest levels of hospital administrators to one man doctors’ offices. These people can be very clever in the way that they operate. In fact to avoid arousing any kind of suspicion, they may set up complicated billing structures and try to cover their tracks. This can make it very difficult for health care fraud investigators to pursue a line of enquiry… False billing is one of the most egregious areas of health care fraud. Hospitals and physicians may bill Medicare for treatment, drugs...
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...Reporting Practices and Ethics Nicole Anderson HCS/405 March 16, 2015 Joe Gazdik Reporting Practices and Ethics According to The Chron, Generally Accepted Accounting Principles (GAAP) are accounting standards used in the United States that allow the recording and reporting of financial information in a uniform manner (2015). As a benefit Companies can ease the burden of comparing financial statements by using GAAP. GAAP also aids in health care to establish creditworthiness of the business or organization and earn a rating of financial strength. GAAP allows business to use actual accounting. By using GAAP companies can report outstanding revenue. A company has the ability to show an acquisition or money that is guaranteed but not yet received, such as a government grant, which provides a higher net worth than if the cash accounting method were used. Monies defaulted by clients or patients is may not be included. This process is called a contra asset and is reported as a realizable value. According to the National Law Review, with the increased focus by the Obama Administration on financial crimes, health care fraud, and corporate fraud, corporate compliance and ethics programs have never been more important (2010). This article discusses the importance of effective corporate compliance programs and ethics programs. These Guidelines will help permit reductions of a subsequent sentence, culpability score, for organizations that have shown to have effective compliance...
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...This business proposal will first exemplify the importance of an outpatient facility. This facility will benefit the patient but also the communities and this organization. The Hope is an outpatient facility that is own and operated by Hope Mental Health Hospital. The Hope has an Outpatient Mental Health Clinic/Facility. It provides different levels of therapy for the mental health patients. In the Particle Hospital Program (PHP) it is designed to provide four groups of intense therapy that is provided by a license therapist. The groups can be a combination of three group sessions with an individual session or all four group sessions. The patients that enter into the program must be assessed by a license therapist, nurse, and the psychiatrist will assess to see if the patient meets criteria for the program. There are some situations where a patient won’t be accepted in the program. Some of the unacceptable criteria could be related to mental state, physical state, type of benefits patient possess, and other issues. We also provide an Intensive Outpatient Program (IOP). This is a less intense program than the Outpatient Program. The patients will interact in three group sessions a day four days out of the week. The psychiatrist does have to admit the patient into this program. This decision can be made by the nurse who has to be a RN and the therapist. These programs are designed to help the patients maintain, function, and cope with their mental illness. It is...
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...HEALTH CARE MUSEUM DAVINA FITZGERALD MAY 25, 2014 HSC 235/HEALTH CARE DELIVERY IN THE U.S DR. ROBERT HOLLINGSWORTH, DHSC.PA-C HEALTH CARE MUSEUM The following paper is a proposal for the new Health Care Hall of Fame Museum. The Museum will be composed of five exhibits, which are Medicare, Modern Health Insurance, Hospice, Long term care and the Public Health service. The first part of this proposal for the museum will discuss the history and impact of these health care developments on the health care system. The second part will be an overview of how these five exhibits relate to each other in the health care system. Medicare Exhibit 1 As part of the Social Security Act the Medicare Program was signed into law on July 30, 1965 by President Johnson. This program came into place because Americans over 65 could not get insurance. Created in the 1960 it was based on the private insurance system that was in use at the time. Administered by the Centers for Medicare and Medicaid Services (CMS) Medicare is purely a government program Austin and Wetle (2012). Over the years there have been many changes to Medicare to keep it relevant with the changing times for example, the Medicare Prescription Drug...
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...expenditures and inventory. Then anticipated major program changes such as addition and reduction of staff, increases in insurance, increases in usage of supplies or cost of supplies and other unforeseen changes. Once these steps are completed the budget is then prepared. Special finance problems that are also considered are unallowed costs as identified by the funding source. 80% of the budgeted funds are allocated to personnel and fringe benefits leaving the other 20% of funds for program operations. Since GETCAP Head Start’s main objective is focusing attention on the importance of early childhood development, they are constantly working to inform the community of the services that are offered. The program has community partners such as Amerigroup, Sam’s Club, United Healthcare and others. These partners provide an outlet for media used to contact potential parents who could benefit from the services that GETCAP provide.The agency uses social media platforms to inform parents of children in Head Start of programs such as health fairs, programs put on by the children, and general information such as early release days. The program also publishes newsletters every quarter (September, December, February, and May). By using different forms of public outreach such as social media, newspaper advertisements, and the ever important word of mouth, they are able to communicate to potential beneficiaries in a variety of ways and gauge the effectiveness of their communication methods. Program...
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...Customer Information Strategy Convergys Case 1. Convergys, a leader in contract-based business process outsourcing services, has been successful in acquiring high-profile customers (e.g. Verizon, FedEx & Starbucks, among others) across a wide variety of industries. Despite Convergys’ impressive customer list, the company has seen its operating margin decrease about 20% over the past 5 years. Key decision makers within the company believe that this decline is due, at least in part, to issues relating to client retention and acquisition strategies. At present, Convergys classifies its customer accounts into 3 tiers: A, B & C. “A” customers are considered to be of highest value, followed by “B” and “C” customers. Although the idea of internally segmenting customers to most effectively allocate company resources (to maximize profit) is sound, the segmentation strategy ought to be well designed and it must incorporate metrics that reflect specific attributes of the industries being served, while at the same time aligning with Convergys’ overall philosophy and business objectives (such as growth, for example). As evidenced by the continuous decline in Convergys’ operating margins over the past 5 years, contrasted with the high quality service it provides and the growth of the specific companies and industries it services, it is apparent that Convergys’ approach to growth is not particularly effective. In this case analysis, we will provide recommendations on strategies Convergys...
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...Executive Summary As a Fortune 150 company with a 45-year history in the health industry and more than eleven million members under its wings, Humana has become one of the largest health benefit company in the U.S. With its slogan, “Guidance when you need it most”, Humana has gain their success through their diverse business units, outstanding wellness program and reliable customer service. The company is basically operates through two business division: government and commercial. The government division serves everyone who is enrolled in government-sponsored program such as Medicare, Medicaid and TRICARE. On the other hand, the commercial division handles employers groups and individuals under fully insured medical or specialty medical. During the last decade, Humana has undergone many major changes, all of which have boosted the overall company’s performance. Humana current strong market position has much to do with their massive acquisitions and strategic alliances that took place within the last years. Their strategic alliances with big companies such as State Farm and PGA Tour and not to forget their partnership with the government have certainly widened their market scope as well as their products and services. Currently, Humana is actively conquering U.S. and Canadian market; however, they have also started to go global through their subsidiary in Puerto Rico where they provide military personnel serving in Puerto Rico with healthcare services for themselves...
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...Sustainable Business & Enterprise Roundtable (SBER) Assessment Corporate Users April 2015 Introduction The Sustainable Business and Enterprise Roundtable (SBER) service provides an annual, confidential qualitative Diagnostic and Assessment to benchmark Member-Clients against their peers and recommend areas for improvement. This Assessment Report details benchmarks and performance in five component areas, which are rolled up to a weighted SBER Index (Figure 1). The component and index scores are updated with information sourced from participating Member companies on an ongoing basis. This report details best practices for the Corporate Users, comparing PG&E with similar businesses within the SBER. The members of this cohort have been evaluated in five components—Vision and Governance, Strategy, Guidance, Implementation, and Reporting Results—over the past two calendar years. Each component constitutes a weighted portion of the SBER Index score (Figure 2). Members are qualitatively benchmarked by their quartile of performance in each of the five component areas (Figure 3), based on the methodology described in the Appendix. Each SBER Component Rating compares the company against the averages for all Member companies for the current calendar year. The relevant Assessment and Diagnostic questions in each component are detailed below each component score graph. The scoring methodology and a list of participating companies are detailed in the Appendix. Based...
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...At a time of high federal budget deficits and unsustainable growth in health care costs, there is general agreement on the need to eliminate unnecessary spending in health care--and among the leading candidates are fraud and abuse. Despite ongoing, concerted efforts, making meaningful inroads has not been easy."Fraud" refers to illegal activities in which someone gets something of value without having to pay for it or earn it, such as kickbacks or billing for services that were not provided. "Abuse" occurs when a provider or supplier bends rules or doesn't follow good medical practices, resulting in unnecessary costs or improper payments. Examples include the over-use of services or the providing of unnecessary tests. (Another area, "waste," refers to health care that is not effective, and will be the subject of a separate Health Policy Brief.)Endowed with new powers under the Affordable Care Act and the Small Business Jobs Act of 2010, the Centers for Medicare and Medicaid Services (CMS) has been adopting new tools to curb fraud and abuse in the Medicare and Medicaid programs. The new approach amounts to a paradigm shift from the earlier model, in which CMS paid providers first, then sought to chase down fraud and abuse after the fact--a process known as "pay and chase."This policy brief focuses on eliminating fraud and abuse in Medicare and Medicaid and explores the challenges involved in putting the new tools into place. | What's the background? | The true annual cost of...
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...HARLEM UNITED COMMUNITY AIDS CENTER 2014 PROGRAM GUIDE TABLE OF CONTENTS ADHCs ADULT DAY HEALTH CARE (ADHC) EAST - EL FARO............................................................................................................... 5 ADULT DAY HEALTH CARE (ADHC) WEST ............................................................................................................................. 6 HEALTH SERVICES DENTAL CLINIC .................................................................................................................................................................... 8 MOBILE HEALTH PROGRAM................................................................................................................................................. 9 PRIMARY CARE .................................................................................................................................................................. 11 HOUSING FOUNDATION HOUSE EAST ............................................................................................................................................... 13 FOUNDATION HOUSE NORTH (FHN) & FOUNDATION HOUSE SOUTH (FHS) ....................................................................... 14 FOUNDATION HOUSE WEST (FHW) .................................................................................................................................... 15 HRA SCATTER-SITE HOUSING ................................................
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...Asia opens up widest margin over Europe for M&A deals In 2012 Asia-Pacific acquirers completed over 40 per cent more M&A deals than their European counterparts, according to Towers Watson’s Quarterly Deal Performance Monitor (QDPM), the largest margin since the research began in 2008. Companies in the region completed more M&A deals than Europe in a calendar year first in 2009, by a margin of 25 per cent. The research, run in partnership with Cass Business School, shows that Asia-Pacific dealmakers completed 183 deals in 2012 compared to 128 by their European counterparts, and similarly, completed more deals in every quarter of the year. The year-end figures, which contains data on all deals over $100 million completed in the year, show North American companies accounted for 422 deals, well over half of those completed worldwide this year. In terms of performance, Asia-Pacific companies that completed M&A deals performed in line with their MSCI index over the year. Despite an increase in activity by North American acquirers relative to their peers, year-to-date figures show post-deal performance of 1.3 pp below the North American MSCI index. In comparison, European acquirers continued to fare well with a positive performance 2.4 pp above the European MSCI index, even though the volume of deals completed was at its lowest level since 2009. Steve Allan, M&A Practice Leader for Europe at Towers Watson, said: “Asia-Pacific has steadily increased deal volumes throughout the...
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...Part II POLICIES AND PROCEDURES FOR THE PHYSICIANS’ INJECTABLE DRUG LIST GEORGIA DEPARTMENT OF COMMUNITY HEALTH DIVISION OF MEDICAL ASSISTANCE PLANS Published October 1, 2013 PREFACE The Physicians’ Injectable Drug List (PIDL) manual contains basic information regarding Georgia’s Fee for Service (FFS) Medicaid and PeachCare for Kids programs and should be used in conjunction with Policies and Procedures Manual for Medicaid and PeachCare for Kids Part I, Part II Policies and Procedures Manual for Physician Services, and other applicable program manuals. We urge you and your office staff to familiarize yourselves with the contents of this manual and refer to it when questions arise. Use of the manuals will assist in the elimination of misunderstandings concerning the coverage levels and billing procedures that can result in delays of claims processing or payments, inaccuracies and/or denials. The PIDL is reviewed and updated quarterly, it is re-priced annually. Drugs that are not re-priced by the manufacturer or are no longer manufactured, or obsolete may not be re-priced or changed— refer to the Schedule of Maximum Allowable Payments (Appendix A) in this manual. For quality purposes, the PIDL is periodically purged of drugs with no or low (fewer than 50 units of service annually) utilization over a three (3) year period; except for orphan drugs and certain chemotherapeutic agents. Requests for coverage of purged drugs will be considered on a case-bycase...
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