Monument Health – PPO-HDHP

Employer Services Offered Through Participation with Western Providers

Employers who opt for self-funding enjoy the following advantages:

• Claims Process and Administrative Services Flexibility
• Plan Cost and Utilization Control
• Improved Cash Flow
• Choice of Service Providers – can limit the size/composition of the panel
• Flexibility in Plan Design
• Elimination of Carrier Profit Margins
• Lower Operating Costs
• No Medical Loss Ratio Requirements
• Uniform Regulations through ERISA

Physician Membership

Physicians (MD and DO) are eligible for membership (ownership)

in Western Providers Physician Organization

  • Membership advantages include:
  • Vote in corporate business
  • Eligibility for Board membership
  • Favorable treatment in certain provider panels
  • Risk/Surplus profit opportunity for some health plans
  • Eligibility for membership is determined by the Board
  • Membership remains with the physician identified, and may be transferred with Board permission if the physician retires, dies or permanently leaves the service area

Western Providers, Inc.’s network serves leading health plans including Aetna, Corvel, Humana, and Monument Health. By joining the Western Providers network, you invest in the future of quality health care that meets the needs of your patients and your practice.

Revenue and Expenses

Western Providers, Inc. obtains its revenue from access fees paid by its clients, the health plans it serves. Expenses include administrative operating costs, insurance and legal fees.

Western Providers, Inc. pays the expenses related to our provider rate setting methodology, known as the “messenger model”, as part of its services for client health plans.
Western Providers Physician Organization is owned by its physician members. WPPO obtains its revenue from membership and contractor fees paid by the panel of providers, as well as fees it provides for certain consultative, risk management and administrative services. Its expenses include administrative operating costs, costs related to credentialing of providers, insurance and legal fees.
 

How We Are Managed

A governing board of 12 directors guides company policy.

The Board consists of...

  • 6 directors of Western Providers Physician Organization
  • 2 administrative officers of Monument Health, Inc.
  • 4 directors selected by Monument Health

A chief executive officer provides strategic planning and oversees operations of the company.

What We Do

Services include...

  • Credentialing, all clinical providers – NCQA Certified in Credentialing
  • Western Providers is delegated for provider credentialing for all clients (payers) – providers submit one credentialing application and Western Providers Credentialing Committee approval satisfies the credentialing requirements for all clients/payers
  • Monthly, on-going quality measures, reports and statistical analyses are used to monitor the quality of the entire Western Providers panel
  • Network Development, on a payer specific basis for
  • ERISA self-insured health plans
  • Insured health plans
  • Preferred Provider Organizations (PPO’s)
  • Web site: Payer specific provider networks
  • Pricing
  • Messenger model (fee-for-service)
  • Shared Savings model
  • Primary Care Capitation model
  • Compensation Models
  • Discounted fee for service
  • Relative Value Scale
  • Inpatient DRG’s
  • Shared Savings
  • Primary care risk model
  • Provider Education
  • Western Providers provides email alerts and updates from specific clients/payers as Western Providers is notified of client/payer process changes
  • Credentialing
  • Credentialing is conducted with the assistance of an independent credential verification organization that performs primary source documentation. Providers must undergo review and approval by the Western Providers Credentialing Committee. The credentialing/re-credentialing process is conducted in a non-discriminatory manner; credentialing decisions are not made on the basis of an applicant’s race, ethnic/national identity, gender, age, sexual orientation, or the type of procedure or patient (e.g., Medicaid) in which the practitioner specializes, but solely on the criteria referenced by this policy and associated procedures. Western Providers reserves the right to limit participation in the WPPO panel to specialties and number of practitioners needed to ensure an appropriate panel and to limit to practitioners willing to adhere to WPPO requirements.
  • Cost Management
  • Messenger Model – For employer self-funded health plans, the provider network is developed through a legally qualified “messenger model”, an independent pricing process designed to obtain competitive provider costs.
  • Risk-based products – For some health plans, both employer self-funded and insured, a Western Providers panel is developed using capitation or other financing approaches that provide incentives for physicians and hospitals to manage costs
  • Population Health Management