OVERVIEW Health care in the Bahamas, as elsewhere, has been delivered in an extremely fragmented manner. While lengthy discussions occurred in the early 1980s on the feasibility of a comprehensive national health plan, minimal progress was made in making quality health care easily available and accessible. Recognizing the need to control the escalating cost of health care in this country, Care Bahamas Limited, the first Preferred Provider Organization incorporated in the Bahamas commenced business in October 1994. Through an affiliation with Global Life Assurance Company Bahamas Ltd., (Now a part of the Colina Group of companies). Bahamians were introduced to the concept of managed care services in the local market. MISSION Care Bahamas' mission is to provide quality health care in an environment of cost containment. We will review the utilization of health care for quality and appropriateness. We will facilitate the prompt payment for services provided at pre-approved rates from payers with no significant nor catastrophic out-of-pocket expense to subscribers/members. GOALS The delivery of health care is now rapidly changing in the Bahamas. Significant changes are also occurring in the way services are reimbursed to professionals. The traditional indemnity insurance is sharing the market with managed care plans. Alleged malpractice liability litigation is increasing and patients frequently access services regardless of cost and sometimes need. Care Bahamas' goals, therefore, are to: 1. Decrease the utilization of unnecessary services. 2. Standardize the quality of services rendered. 3. Control the increasing costs of health care services. 4. Influence changes occurring based upon knowledge of the local health care market. 5. Develop the premier managed care delivery system in this country.
PURPOSE AND PHILOSOPHY CARE BAHAMAS seeks: 1. To ENLIGHTEN AND EDUCATE Medical Professional Services Providers about the business operation of health care services provision in the Bahamas. 2. To DEVELOP AND FOSTER an organization of informed providers negotiating on cost of services so that an environment of realistic and favourable REIMBURSEMENT FOR SERVICES is maintained. 3. To CONDUCT NEGOTIATIONS on behalf of participants utilizing a corporate entity to enter into favourable legally-binding contractual arrangements with: A) Consumer or Patient Groups B) Third Party payers i.e. any or all health care services benefits providers; C) Institutional services providers; D) Government or National entities, 4. To ESTABLISH AND MAINTAIN A PREFERRED PROVIDER ORGANIZATION (PPO) which will comprise selected health care practitioners who meet the following required criteria: A) Are members in good standing under the Medical Act, the Dental Act, the Nurses and Midwives Act or the Pharmacy Act. B) Are perceived by any and all potential contracting entities to be Providers whose services are desired by that entity C) Are Providers committed to providing quality care consistently to patients. D) Are Providers committed to providing an affordable service which is not only or simply a function of adjusting the real cost of the service. E) Are Providers committed to the concepts of QUALITY ASSURANCE, PEER REVIEW, UTILIZATION REVIEW, PROFESSIONAL AND BUSINESS AUDITS. 5. To ESTABLISH A REGIONAL NETWORK of professional and institutional services providers, participating through the frame work of MEDICAL CASE MANAGEMENT, while providing extended care to patients so referred.
OBJECTIVES 1. Care Bahamas aims to retain a select panel of providers. There are currently sixty enrolled physicians and three non-physicians. Efforts will always be made to contract providers on the basis of their professional skills, competence and scope of services. The requirement that participating providers be credentialed and/or certified specialists is of equal significance. In distinct circumstances, providers are enrolled on the basis that they provide services subject to the optimum level of training. 2. We strive to maintain negotiated payment rates. Providers agree to accept Care Bahamas' payments as payment in full excluding applicable coinsurance and co-payments. Negotiated payment rates may take the form of discounts from charges or may be formulated based upon the Bahamas Medical Association Fee Guidelines and other recognized fee schedules. 3. In exchange for favorable payment rates, Care Bahamas will continue to guarantee a rapid payment term. 4. Quality control standards are constantly being developed and upgraded. Of significance: A) Provider Credentialing -includes certification as well as maintenance of CME credits. B) Periodic review and recertification of providers - includes utilization and outcomes profiles. C) Establishment of standards for medical records and monitoring of compliance with standards. D) Adverse events monitoring e.g., unplanned transfer to ICU, unplanned return to surgery on same admissions and myocardial infarction on same admission. E) Monitoring potential deficits in quality of ambulatory care, including ruptured appendix, complications of diabetes and late stage breast cancer. F) Utilization management programs are featured so as to prevent over and under-utilization and maintain appropriate cost of health services. G) Consumer choice remains available. Members are at liberty to use non-PPO providers; however, greater costs and risk are transferred to the member. H) Follow-up care notices are provided for abnormal tests, radiographs and symptoms. I) Evaluation of performance against practice guideline e.g. immunization patterns in children, annual pap smears and mammograms. J) Developing member satisfaction surveys. 5. We will assist providers in improving their practices especially with respect to user friendly billings. Additionally, we will provide support and updates about new practice management methods and technologies.
THE PRINCIPALS Care Bahamas is a Bahamian owned company and was incorporated by five physicians and one managed care executive. This group includes: Drs. Baldwin Carey, Barrett McCartney, Charles Diggiss, Robin Roberts and Conville Brown, and Mr. Charles Jackson. The doctors are all credentialed specialists. Mr. Jackson is the President and Chief Executive Officer of Florida Medical Provider Network, a managed care entity located in Miami, Florida. MANAGEMENT The above principals serve as company directors and assume ultimate responsibility for the success of the company.
STRATEGIC ANALYSIS LOCATION Care Bahamas is, ideally, Shirley Street. This location is advantageous because of the close proximity to Doctor's Hospital, Princess Margaret Hospital and numerous physicians’ practices and insurance companies. MARKETING Care Bahamas aims to provide services for insurance companies, employer health benefit plans and other managed care companies. Our marketing efforts also extend to health care providers so that we always maintain adequate representation. Primarily a network of physicians, we aim for representation of all locally available areas of specialty. Additionally, the network is expanding to include ancillary services such as laboratories, pharmacies, imaging centers, chiropractic, podiatry and physiotherapy.
Traditionally, insurance companies advertised PPO facilities, but the benefit was available for overseas services only. On April 1, 1997, we formed an alliance with British American Insurance Company of the Bahamas, Ltd. to provide professional health services to members enrolled in the MEDIFLEX plans. Established in the Bahamas in 1920, British American has developed a reputation of providing high quality health insurance products in the Bahamas. In response to market demands, it launched the MEDIFLEX SILVER product which provides enrolees with access to managed care services locally, via Care Bahamas, and internationally, via ChoiceNet Managed Care Services in the United States. In August, 1998, our organization was expanded to include services for Imperial Life Financial’s ASSURE program. Under the contract with both British American and Imperial Life, we provide primary and specialty health care services as well as utilization review and quality control management. Given the wealth of experience gained during the last three years, Care Bahamas is strategically positioned to remain at the forefront of the local managed care market. We offer not only provider services, but a rather comprehensive array of management and administration capabilities. The Care Bahamas advantage includes: 1. The involvement of key physicians in both the public and private sectors on its directorate. 2. The representation of four (4) significant out- patient/ambulatory comprehensive care facilities on its directorate. 3. The representation of the premier pre-hospital emergency advanced life support ambulance service (Med-Evac) on its directorate. 4. The involvement of physician managers with integral roles at both the Princess Margaret Hospital and Doctors Hospital. GENERAL PRACTICE FAMILY PRACTICE PEDIATRICS' OBSTETRICS & GYNECOLOGY ANESTHESIOLOGY DERMATOLOGY NEPHROLOGY /DIALYSIS CARDIOLOGY PEDIATRIC CARDIOLOGY INTERNAL MEDICINE GASTROENTEROLOGY INFECTIOUS DISEASES
SURGERY
GENERAL CARDIOVASCULAR EAR, NOSE & THROAT NEUROSURGERY OPHTHALMOLOGY ORAL (MAXILLO- FACIAL) ORTHOPEDICS PLASTIC & RECONSTRUCTIVE UROLOGY
OTHER SERVICES PODIATRY CHIROPRACTIC COST CONTROLS Care Bahamas monitors and controls healthcare costs and quality which are reflected in the following services. 1. CLAIMS REVIEW Claims are reviewed in accordance with the benefits and/or exclusions outlined in the clients' insurance plans as well as on the basis of medical necessity and appropriateness. 2. MEDICAL RESOURCE MONITORING Healthcare providers adhere to established rules and guidelines in order to obtain payment from insurance companies. This allows medical services to be monitored consistently. Providers sign a contract as a basis of enrolment in the network. Failure to comply with written rules is a breach of the contract which may result in termination from the network. Monitoring mechanisms include: Pre authorization; Proper use of CPT and ICD Codes; Maintaining established reimbursement levels; and Quality Control Management. 3. PREAUTHORIZATION A. Pre authorization is required for: -Hospitalizations. -Overseas care. -Out-or-network services. B. Authorization is provided when the services are considered medically necessary under the plan's definition. The service must meet the following criteria: -It is appropriate for the diagnosis being reported. -It is provided in the appropriate location. -It is not provided for the patient's convenience or that of the family. C. Preauthorization requests are made by the attending physician. D. Preauthorization is provided by a medical director, or a panel of credentialed physicians when warranted. 4. CHECKS/AUDITS Our personalized computer software has been developed to maintain an accurate account of the claims process. It also monitors all claims for duplicate billings and excessive encounters. A. Duplicated billings are denied. B. Patient encounters, within a single year, for the same diagnosis or condition are reviewed for medical necessity when: I. Office visits exceed three. II. Hospital visits exceed five during a period of hospitalization. Adjudication is withheld pending determination of medical necessity in any case exceeding these limits. Insurance companies and plan administrators are ultimately responsible for provider reimbursement however. 5. MONITORING PHYSICIANS COST Physician payment relates to the CPT code. Consideration is given to: -The maximum allowable rate (MAF) which is the Resource Based Relative Value Scale multiplied by the conversion factor. MAXIMUM ALLOWABLE FEE (MAF) = RBRVS X CONVERSION FACTOR - The RBRVS is calculated by totaling three separate unit values:
- HealthCare Consultants of America, Inc. Physicians Fee Coding Guide for CPT codes and relative values -The usual, customary, and reasonable rate is a consideration in circumstances where a rate may not be readily available (e.g., a new or rarely performed, highly complex procedure) or if the negotiated rate is considered exorbitant for the local market. 6. UTILIZATION MANAGEMENT Utilization management refers to the management of care and ensures the reimbursement of medically necessary services. A. Physician peer review profiling Peer Review is a process in which physicians review the care provided by other physicians on a retrospective basis to identify abnormal practice patterns. Claims data are used to identify which physicians generate the highest cost for the specialty in comparison to their peers. Investigation confirmation or dispute resolution is ultimately the responsibility of the medical directorate. Consideration is given to, among other things: -The number of patients seen. -Total cost/patient treated. -Average number of encounters per patient. -Average number of procedures per patient. -Number of inpatient admissions. -Average length of stay. -Hospital cost per inpatient. B. Medical Directorate The medical directorate is comprised of five physicians. They are responsible (subject to areas of expertise) for monitoring the clinical care provided by the health practitioner. This panel of directors is assisted, as the need arises, by Peer Review Committees which are comprised of credentialed providers. C. Case Management The case manager intervenes in cases where extraordinary costs are involved. The focus is to arrange alternatives to catastrophic care. The case manager can authorize benefits that are not usually covered in the policy with the intent of decreasing the cost of care. The case manager is a licensed registered nurse with more than twenty years of experience in the nursing profession. D. Quality Improvement The medical director is also responsible for quality improvement which is the process of monitoring quality of care. Quality improvement is used to monitor the clinical care in such a way that it is always being improved and so that patients have access to the services required. F. FEES Physician rates are negotiated on the basis of the Bahamas Medical Association's fee guidelines. | |