Independent Practice Association Mgmt.

Independent Practice Association (IPA) Management Services

Mission Statement
To empower independent physicians to deliver exceptional, patient-centered care by providing the resources, strategic partnerships, and support they need to succeed in an evolving healthcare environment, while advancing the health and well-being of the communities we serve.

Vision Statement

To create a thriving healthcare environment where independent physicians lead, patients receive high-quality care, and local partnerships foster healthier communities for generations to come.

(IPA) Management Services

Mailroom
The Mailroom team is responsible for the recording and the distribution of incoming mail received for each line of business.

Eligibility
The Eligibility Department is responsible for maintaining member eligibility and records provided by the health plans. Other functionalities of the Eligibility Department are to maintain the claims processing system with coordination of benefits information (primary, secondary and/or tertiary insurance benefits).

Benefits
The Benefits team is responsible for maintaining and creating plan benefits provided by the health plans. Other functionalities of the Benefits department include working cohesively with the Managed Care department to update/add providers according to contract specifics (demographics, reimbursement rates, etc.). The Benefits team will set the claims processing system based on the DOFR (Division of Financial Responsibility) agreements for service provided.

Claims
The Claims Department focuses on processing medical insurance claims received by rendering providers and facilities according to the processing guidelines put in place per the financial risk agreement of each health plan.

Customer Service
The Customer Service Department provides support and assistance with telephone inquiries from physicians and members. Representatives address questions, investigate concerns and complaints, and document interactions to ensure appropriate follow-up and resolution. When an issue cannot be resolved directly, representatives coordinate with or refer the caller to the appropriate department for further assistance.

Cost Containment
The Cost Containment Department identifies and controls the cost of non-contracted provider services. Cost Containment is responsible for payment recovery and the handling of written provider inquiries or provider disputes regarding reimbursement.

Compliance
The Compliance team enforces quality standards per the delegation agreement of the health plans. Our compliance team is also responsible for presenting claims data information to the health plans at their request or during annual audits.

Quality Improvement
The Quality Improvement department works closely with all departments of Santé Physicians IPA to ensure quality of services is being provided to internal and external customers. They also provide assistance on higher level inquiries that could not be resolved through the Customer Service Department.

Utilization Management
The Utilization Management Department is staffed with clinicians and paraprofessionals who play a key role in managing medical costs in this system. In consultation with the Vice President of Medical Affairs and Associate Medical Director, this department determines medical necessity of procedures, length of hospital confinements, and appropriateness of ancillary treatment. Utilization Management is also responsible for providing treatment authorizations and monitoring treatment patterns and utilization trends.