Misc. Questions Flashcards
Blanket Provider Approval
-Allows an employer to specify a set of providers that approved for Garner reimbursement, regardless if a member finds them through the app
-Common request among healthcare groups
Note: This is an MVP solution, use best judgement
How does Garner work with level-funded groups?
We quote them the same way as fully insured
How does Garner work with HMO’s?
If the HMO requires a referral before seeing a specialist, we don’t recommend adding Garner
We can technically support it, but it can create a confusing member experience
-they might find a doc using Garner, but then don’t get that referral so they’re stuck
How are you ingesting the hospital transparency data?
We actually built our own engine to ingest that information
How do we know if someone is up-charging for visits?
Site infection at Mayo Clinic: What about the nurse that does the stitches? Couldn’t they cause the infection?
These doctors are using the same operating rooms, same support staff
-They’re working down the hall from one another
-There’s a constant here, it’s the doctor
-Hence why the infection is tied back to the doc
Maybe the doctor is giving better instruction to the team, or even the patient on how to take care of themselves at home
Garner’s Closed Data set perks
Able to track members across different carrier networks
-Ex: Someone is with UHC one year, and moves to Cigna the following year
-Means, UHC loses track of patient
-If Joe gets a knee surgery with UHC, then the carrier switch happens, UHC doesn’t know about infections, complications, or revisions
Garner however, can follow that patient
-much more accurate into the quality of that surgeon
How do you compare to Surest?
Similar philosophy, getting employees to higher quality care. 3 major differences:
1. Surest is more disruptive, ID card says Surest
-Garner works with existing carriers and network
2. Can’t have Surest on a HSA plan
-Fully copay-driven plan, so employers have to rip those out. Garner works great with HSA’s, actually see slightly higher engagement with HSA plans over PPOs
3. Most importantly, Surest is based on different data
-Episode groupers, not effective at identifying higher quality doctors
-Garner has much more data, take a bottoms-up approach to determine which doctors are best quality and lowest cost
-Does the network matter in your recommendations?
Yes, we only make recommendations for in-network doctors
Also take into account network discounts
-Ingesting health plan transparency data helps us know how cost varies from doc to doc, or plan to plan
Network discounts do impact cost of care, so it’s factored into our recommendation
Ex for Practice:
-$1000 with Dr. Smith
-UHC has 20% discount
-Cigna has 25% discount
How does Garner work with Tiered networks and domestic steerage?
We have experience working with large hospital systems
-Mercy works with Garner to understand how their doctors perform
We can help with domestic leakage, steering folks to high-quality doctors when they looks outside hospital system
What is the HRA Funding Fee?
This is in place because we’re guaranteeing the cost of the program for 12 months
However, those dollars are budgeted to be used by the HRA
-expect to pay those dollars out as reimbursements, and not meant to be additional rev. for Garner
-Main thing to know: These dollars are not eligible for the return via the 80% settlement if there’s lower utilization
If higher than expected utilization happens, Garner is on the hook to cover any overages
-So this is how we balance the financial elements
How is HRA Funding calculated?
How do you reconcile the Performance Guarantee at the end the year?
Start by saying we think we’re going to save you X % on your claims spend, say 10%
-Of that 10%, we’re going to guarantee a portion, maybe 5.5%, 6% for example
-If we don’t hit the guaranteed savings target, we refund up to 3x our admin fees to make you whole
How do we reconcile that? At the end of the year:
-Take your historical claims spend to figure out what your expected claims spend would be in the upcoming plan year if you renewed as it
-Then, look at the claim spend in the year with Garner after you cap for high-cost claimants ($50k)
NEEDS MORE WORK
What’s the communication campaign look like for Garner?
Can see we’re heavily invested in marketing Garner to employees, especially since we’re putting our money on the table to hit a certain savings target
Make sure that not only employees know they have Garner
-But how it works, how to take advantage of it
-In the end, we only hit our savings target if people use the program
OE support includes:
-One pagers, email and text campaigns, direct mailers, videos
-Designated AM team is tasked with figuring out best comms strategy for each population
-we understand each group is a little different
Performance Guarantee % for Overlay, Increased, Enhanced
we guarantee 1% Overlay, 5% Increased, 9% Enhanced
Continuation of Care - what it is and examples
Continuity of care
Be careful when you’re presenting this, it’s not black and white
Case-by-case exception
If folks are undergoing for an ongoing treatment for an active condition, we may or may not cover that existing doctor even though they’re not recommended as a TP
Ex: Employee is going through chemo with a specific oncologist, currently undergoing active treatment. We’ll continue to cover that doctor
But, if employee has been in remission for 3 years, and going for 6 month check up and isn’t actively being treated, probably an instance where Garner wouldn’t cover that doctor relationship
CoC is much more stringent
“Know this sounds like a cop out. We really shy away from making broad generalizations on the continuity of care policy”
Get member-facing language for CoC from Jake (from training with Rob and Rick)
Short answer: It depends
What does Garner define as an emergency? (Asked when Garner is covering ER care)
We define emergency as: Does the underlying medical plan define it as a true emergency
Ex: Sniffles and go into the ER, Garner is not going to cover it either
Deferring to the medical carrier to determine what emergent is
How many doctors in any given network are identified as Top Providers?
Usually 20% - 30% within an existing network
What is a Disruption Report?
(Main Answer)
Analysis of a prospect’s specific claims and network to show:
-% of providers visited by members that are top doctors
-estimated savings if all members visited top doctors
Details
% if top provider metric:
-Ranges from 20%-35%
-we expect higher % in rural areas b/c proportion of top providers is greater there
Estimated Savings:
-Take every non-top doc, calc. avg. % cost diff. with TP’s in that specialty and region
-multiply % by claims amount, sum differences to arrive at total
What’s required to run a Disruption Report?
What doctors were visited in the last few years and what $ amount was spent on that doctor
-Rendering provider NPI’s required
What’s a Geoaccess report?
Analysis showing % of employees in a given region that will have access to top doctors available for Garner reimbursement
Report Standards:
-Ensure that all recommended providers are within an acceptable distance from the employee
-Drive time based on where the employee lives, and the volume of that speciality
What’s required to run a Geoaccess report?
-Full census of employees with zip codes
-Network name
What is broker commission?
What is Garner’s admin fees PEPM?
What reporting does Garner offer to customers?
We provide quarterly reports showing:
-what folks are searching for
-who’s signing up
-the amount of Claims $’s being reimbursed
Can also provide that reporting ad hoc if requested
How long does implementation typically take?
What data are you using to find the best performing doctors? (Succinct response)
We’ve aggregated medical claims from pretty much every source out there
-From insurance companies, clearinghouses, HT data
-As well as 3rd party partners
These sources stitched together give us largest claims database in the country, over 310 million patient records
Then we use in-house quality metrics to rank doctors
How does your PEPM change for single vs. with dependents?
Garner’s fees are tired depending on enrollment
What is Garner’s minimum incentive amount?
$1,000
How long does it take for an employees to get reimbursed?
With claims feed: 7 weeks from date of service
Member-initiated claim: check or direct deposit 3 weeks from when they submit claim to Garner
