Rely on Our Expertise for Medicare Advantage Entry
Meeting the Health Needs of an Underserved Community Through a Medicare Advantage Plan
Rapidly launch a Medicare Advantage (MA) plan to expand healthcare benefits to a community unfamiliar with MA options
Change Healthcare Consulting’s Medicare Advantage Entry Program
- Implemented a new MA plan within a shortened time span
- Successfully prioritized member interactions and engagement
- Paid 99% of claims in fewer than 30 days
- Expanded plan offerings to additional markets in Illinois, Michigan, and Indiana
Zing Health’s mission is to reduce healthcare disparities among diverse populations chronically underserved by traditional insurance plans. The health plan was founded by doctors who envisioned creating a collaborative, community-based managed Medicare Advantage (MA) plan to support physician-patient relationships, address social determinants of health, and ultimately improve health outcomes.
“We wanted to attract new patients who weren’t aware of how this type of insurance could help them stay healthy and well. Our goal was to become part of the fabric of the community, helping everyone improve and maintain their health.”
Garfield S. Collins, COO and co-founder of Zing Health
The Challenge: Launching an MA Plan on a Deadline
In 2019, Zing Health began a journey to introduce an MA plan in Cook County, Illinois—the county that encompasses the Chicago metropolitan area. The organization was eager to begin meeting the needs of this community and was looking to fast-track the application and implementation process, aiming for enrollment in 2020. A typical MA journey can take two to three years, but Zing Health leaders were adamant about moving faster to get essential benefits to members sooner.
“Our vision was to create a plan for everybody in the community, but in particular, those whom other MA plans fail to serve,” said Garfield S. Collins, COO and co-founder of Zing Health. “We weren’t looking to take members from existing plans. We wanted to attract new patients who weren’t aware of how this type of insurance could help them stay healthy and well. Our goal was to become part of the fabric of the community, helping everyone improve and maintain their health.”
Health plans face significant hurdles when launching an MA product. The program is highly regulated— much more than commercial insurance plans or exchanges—and plans must navigate more than 30 manuals of regulatory guidance. Due to the myriad changes made to the program each year, effectively implementing, running, and keeping an MA plan in compliance requires in-depth knowledge, expertise, and vigilance.
“As we began the journey, we quickly figured out we needed somebody to guide us through the process, helping us submit a bid to CMS, assemble a provider network, and develop a staffing and technology infrastructure to support the plan,” said Collins. “We wanted somebody who had done this work before and could fully realize our vision efficiently. Given the complexity and scope of what we needed and the abbreviated timetable, the list of potential partners was short. I’d had experience with Change Healthcare before, and I knew that I could get a straight answer from them on the project’s feasibility and what it would take to implement it. They were refreshingly honest about the uphill battle we faced and provided clarity around the work. They also communicated their readiness to dig in and get started, and we knew we’d found the right partner.”
The Solution: Partnering with an MA Expert Helped Realize the Vision
Change Healthcare Consulting’s Medicare Advantage Entry Program guides health plans through the complex, lengthy process of launching an MA product, offering a road map to application, approval, and implementation. The Change Healthcare team includes experienced subject matter experts in areas ranging from compliance, enrollment, utilization management, appeals, grievances, and member services to technology. For the Zing Health project, 15 consultants partnered with the health plan’s executives to outline, drive, and execute the work.
“We leaned on the Change Healthcare team during this time because we didn’t hire our own staff until later. Using their expertise, the group helped us make decisions around how the MA plan would function and then helped us turn those decisions into actions.”
Garfield S. Collins, COO and co-founder of Zing Health
Submitting the Application
The first step was to submit the application to CMS. Change Healthcare consultants helped Zing Health leaders understand the various application components and how to meet all the requirements. For example, contracting with a pharmacy benefit management (PBM) company is an essential part of the CMS application, as the agency will not let an application proceed without a signed PBM contract. The Change Healthcare team is experienced in helping health plans establish a relationship with PBMs to support the pharmacy benefit administration requirements. Change Healthcare helped Zing Health identify a qualified, available pharmacy partner and guided the process of creating an agreement.
Building a Network
Next came the task of constructing the provider network. Zing Health had definite ideas on the providers they wanted. “Our goal was to have the plan enable the patient-provider relationship and help address social determinants of health,” said Collins. “We wanted to make sure the network included physicians, nurses, and other providers who shared our vision and were willing to collaborate with patients around their health.”
Change Healthcare consultants worked diligently to identify and contract with providers in the community who met the criteria, ensuring an appropriate balance of primary care physicians, specialists, hospitals, skilled nursing facilities, and so on. “We made a conscious decision to focus on Cook County, because we believed we could build a network there more easily due to a Medicaid plan we already had,” said Collins. “We relied on the Change Healthcare team to help expand the network and facilitate contracting and credentialing.” Within four months, the consulting team had an initial network in place.
Focusing on Infrastructure
The Change Healthcare team worked concurrently to help Zing Health develop an infrastructure that would support MA market entry in 2020. This included constructing the organizational chart, generating policies and procedures, securing facility space, and selecting benefit management and claims processing technologies. “We leaned on the Change Healthcare team during this time because we didn’t hire our own staff until later,” said Collins. “Using their expertise, the group helped us make decisions around how the MA plan would function and then helped us turn those decisions into actions.”
Implementing a Platform for Claims Processing
Early in the process, it became clear that Zing Health needed a platform to handle its backoffice claims processing. Given the tight timeline, however, the organization did not have the luxury of a comprehensive RFP and bidding process to inform vendor selection, which is typically a key component in Change Healthcare’s Medicare Advantage Entry Program.
When Change Healthcare’s Business Process as a Service (BPaaS) team stepped up to offer its services and solutions, the Zing Health team saw an opportunity to leverage the necessary technology and stay on track with its deadline. Built on a nextgeneration benefits administration and claims processing platform that supports CMS compliance, BPaaS streamlines claims processing, payment, and monitoring.
“Given the short project timeline, using BPaaS represented our best option to get the services and technology we needed when we needed them,” said Collins. “By having BPaaS handle core functional and business processes, we are able to focus on member interactions and engagement, including customer service, prior authorization, utilization management, and other direct member and provider interactions.”
Results: Meeting the Needs of All Stakeholders
In January 2020, Zing Health went live with its MA plan for Cook County. The organization reached its initial membership targets, which were intentionally low to allow for easier adjustments to operations. Current members receive a comprehensive benefit plan that includes medical, dental, vision, and other services that encourage total health management.
Given the positive response, the organization is now entering other markets in Illinois, Michigan, and Indiana.
“Expanding the plan has its own set of challenges, not the least of which is the pandemic, which has limited our ability to hire staff and market the product,” said Collins. “Even with those difficulties, the plan is growing.”
Although the implementation process wasn’t perfect, Zing Health views it as a success. “We’ve had almost no complaints from providers about payment, members seem to be happy about the level of service, and CMS has been supportive as well,” said Collins. “We pay 99% of claims in less than 30 days, and the majority of our denials are related more to logistics than program concerns.”
The relationship between Change Healthcare’s consulting and Zing Health’s leadership was key to the project’s success. “What we loved about the Change Healthcare team was their flexibility,” said Collins. “They would brainstorm about different ways of doing things based on data, their experience, and their desire to help us meet our goals. Bottom line: It was and continues to be a great partnership.”