Payviders & Risk-Bearing Providers
Provider organizations that carry financial risk for the care they deliver — through a health plan they own or operate, or through capitation and other downside-risk contracts. A workforce decision is a revenue decision, and cost you shift out of one side lands in the other.
- Health systems that own a health plan
- Provider-sponsored insurance organizations
- Capitated medical groups
- Risk-bearing IPAs and MSOs
- ACOs in downside-risk arrangements
- Integrated delivery systems with material delegated risk
The test is downside risk. An ACO in a shared-savings-only arrangement stays on its home route — healthcare provider or community health — with the arrangement noted, because it does not yet bear the loss when costs run over.
Two diagnostics, equal weight.
The workforce side
Clinical labour cost, contract-staff dependency, turnover, and the benefits structure that is supposed to hold people in place — and, where you run a plan, its staff too.
The revenue side
Revenue integrity, plus what a provider without risk never sees: risk-adjusted revenue, utilization economics and contract performance.
Data. Provider data plus enrollment, claims, attribution, risk contracts and utilization, alongside finance and HRIS.
A provider that also runs the plan.
A payvider is a provider enterprise that owns or operates a health-plan or financing function. It delivers care through its own clinicians and facilities, and it carries the financial risk for that care through a plan it runs.
Being self-funded is not the same thing. A health system that funds its own employee health plan carries claims risk on its workforce — that is employer risk, and BenDNA examines it for every provider. The payvider model starts when the enterprise also operates a plan or financing function as part of its business.
That is why a payvider engagement needs two sets of people in the room. The provider side — revenue cycle, operations, workforce — answers for the care. The plan side — plan administration, plan finance, medical economics, network engagement — answers for the risk. One executive rarely answers for both, and a diagnostic that hears from only one side is half complete.
Both diagnostics run, and they run together. A plan-design or network change moves utilization, which moves claim volume through your own revenue cycle. Run one diagnostic and the effect shows up in the other as an unexplained variance two quarters later.
Where it starts
- H.E.R.O. Snapshotno costOne for each driving force. Each shows where that force is most exposed — you answer about the system you actually run.
- BenDNA / RevDNApaidOur proprietary Diagnostic Needs Assessment. Surfaces the specific gaps in your operations and produces the Economic Case our ecosystems are built against.
- BenECO / RevECOpaidThe selected capabilities, delivered and measured as a scoped engagement — with terms set for each component.