skip to Main Content
Commonly Asked Questions By Health Plans Seeking New Solutions-Services

Commonly Asked Questions by Health Plans Seeking New Solutions-Services

Part 2: Services Exploration

We continue our series on the most common questions by focusing on our services sector. For a quick review, HealthAxis Group offers an array of third-party administrative services that help accelerate productivity, improve processes, and perform cost-efficient operations for Medicare, Medicaid, and commercial plans. We customize service engagements, from outsourcing all plan operations to targeting a single line of service (full list of services)

With that information, let’s dive into our responses to the services questions frequently asked by health plans.

How do you house and report on the data for 5 Star? And, what support do you offer to help improve ratings?
A health plan’s rating is based on five different category measurements:

  •     Staying Healthy: Screenings, Tests and Vaccines
  •     Managing Chronic (Long Term) Conditions
  •     Member Experience with Health Plan
  •     Member Complaints and Changes in the Health Plan’s Performance
  •     Health Plan Customer Service

We have added specific fields and the ability to have user-defined fields for data capture and reporting of STAR requirements within our core system to make it easy for health plans to monitor all the data points.

Many components factor in supporting health plans to deliver high-quality care and high beneficiary satisfaction. Our in-depth understanding of the healthcare industry and strong partnerships with our clients enable us to provide tailored solutions, best practices, and improvements that address all the different metrics that impact scores.

To start, our senior compliance specialist monitors CMS regulations and oversees the daily MLN, monthly updates, quarterly changes, and all chapter changes. We dedicate and train staff to become an extension of our client’s operations, helping to ensure timely and standardized responses to member concerns and consistent handling of complaints and grievances. Furthermore, removing error-prone processes and harnessing real-time data help improve results.

These are just a few approaches that led our large Medicare Advantage plan partner to grow membership from 12,500 to 150,000 members and improve star ratings from 2.5 to 4.5/5.

What is the experience level of your claims processing staff?
Currently, 75% of our processing staff has been with our team for more than four years and is versed in processes for Medicare HMO, PPO, PFFS, and commercial claims. Our claim processors have extensive training on each specific type of claim and receive ongoing training as processes change. The department has an overall processing quality score of 98.4%.

What is your team’s process for escalating appeals and grievances?
During an implementation phase, the escalation process is explored with your team to ensure each escalation scenario and treatment plan is defined per your plan’s expectations. An instance may occur when a case gets converted from a standard appeal to an escalated appeal or when a case must be handled more urgently or delicately, either due to the member’s medical condition, escalations to regulators or at the request of the health plan. In addition to following the Regulations for Timeliness, we follow the Medical Exigency Standard in which we work to make decisions as expeditiously as the enrollee’s health condition requires. Additionally, the Appeals and Grievances Department will notify your team of those additional escalations and will collaborate through the completion of the case.

Can you handle intake authorization requests from multiple sources (e.g. electronic, written, and live chat via phone)?
Authorization requests can be accepted through various sources. Written requests are accepted via fax or through our mail room services and processed within CMS time guidelines. Telephone requests are received through customer service, provider services, and member services. Electronic requests can be submitted via our real-time provider portal, an extension of our core claims system. A provider can send an authorization or referral request through the provider portal.

What Internal auditing processes can we count on to confirm that the integrity and quality of data storage and reporting are in accordance with State, CMS, HIPAA regulations?
Our data integrity, quality of data storage, and reporting are regularly reviewed by outside auditors to assure conformity with industry standards, including but not limited to CMS and HIPAA. In addition, we work with our clients to understand and address any specific state or client’s needs. Plus, we provide monthly oversight and maintenance reports to our clients.

We hope you found these answers helpful. Our final segment focusing on analytics is on its way soon.  As always, feel free to reach out and schedule time with us to discuss specific questions regarding your unique situation.

Back To Top