As regulatory reform becomes more complex, healthcare organizations struggle to improve compliance, increase productivity, raise quality scores, minimize penalties, enhance reporting, and boost member satisfaction. By taking advantage of the flexibility of our accredited services and solutions, your organization can streamline the appeals and grievance process. Your team can view, enter, and update appeals and grievance cases as well as export logs in PDF and Excel formats. Our reporting feature includes fields for all documentation and can be configured to support existing and new requirements. Data reports are provided on a weekly and monthly basis.  The reports include inventory received, timeliness of processing, amount of upheld or overturn decisions, amount of cases dismissed, amount of pending cases, and more.

Your team will be able to:

• Enroll and reconcile members thoroughly and efficiently
• Obtain the highest STAR ratings for quality care
• Record and report on critical quality and compliance measures
• Execute successful audits with CMS and AHCA

We understand that the core of your success lies with an efficient and flexible claims administration system. Our easily configurable, cloud-based claims processing and adjudication solutions for commercial, Medicare, and Medicaid markets reduce the cost of technology ownership and allow for rapid implementations. You can administer plans across multiple lines of business, achieve greater levels of operational efficiency, and plan for future needs.

On average we process 98.5% of claims within 30 days with financial accuracy at 99% and statistical accuracy at 100%.

Claims can be received in multiple formats. Our determinate engine gives you the ability to specify parameters or rules according to CMS processing guidelines and payment methodology as well as individual health plans. You can accurately process, pay, and store claims and claims payment remittance advice/EOPs/EOBs. We provide claims management solutions to help you achieve your business goals.

• Lower administrative costs to better meet medical loss ratio and other regulatory requirements
• Increase the accuracy of your claims adjudication rates
• Integrate claims edit and re-bundling
• Manage complex benefit and reimbursement methodologies
• Complete HIPAA compliant transactions
• Eliminate paper workflow
• Batch claim re-processing for specific providers, contracts and various bulk criteria
• Configure fuzzy logic such as check duplications and authorization matching
• Print Claim and Capitation checks
• Improve claim queues and workflows

Our consulting services will guide you through your toughest regulations and compliance challenges.

We provide an integrated framework that revolutionizes compliance processes. We speed reaction time with coordinated, multi-channel communications, intent-driven work processes, compliance reporting, real-time performance monitoring, and analytics to minimize risk.

We tailor solutions that fit your requirements and provide continuous value throughout your organization. Our advisory support enables you to maintain sustainable HIPAA programs, reduce future costs, and boost the efficiency of key processes. Our information security team is well versed in the HIPAA privacy and security rules, and breach reporting requirements.  They can perform vulnerability assessments, web application security tests, network hardening, source code analysis, and thorough risk analysis against all major frameworks for you and your team.

Reduce the time it takes to get your providers and members enrolled by having the right services in place. With our trained staff and systems, you can quickly merge provider information with Medicare, Medicaid, and other payer forms to expedite the enrollment process. Effortlessly process applications, adjust coverages, manage reconciliations, administer member correspondence, and deliver reports. We plan and schedule for, benefit plan configurations, payment reconciliations, and annual rollover actives. Take advantage of our Compliance and CMS expertise.

We offer:

• A strong system knowledge base that provides a practical road-map to improvements
• Ongoing compliance monitoring
• Distribution, discussion, and training regarding all CMS memos and guidance updates to all employees
• Continuous education for CMS system releases and process updates
• Strong knowledge of Ch. 2, 3, 4, 9, 12, 13 and other Medicare prescription drug benefit manuals
• Internal process for compliance oversight

Now more than ever, consumer expectations are driving health plan operations. Consumers want real-time information that is easy to obtain and digest. To deliver responsive, transparent customer service, the most successful organizations are taking step toward providing, monitoring, and ensuring that consumer engagement takes place consistently throughout their member journey.

By proactively developing outreach and account management, you can increase the value for customers and ultimately raise member retention. Our team has the experience to guide you and can lessen the burden on your team by providing member communications and mailroom services.

Our Mailroom Team and Services

Has a daily turnaround of 95-100% of mail received on the same day

Can process up to 84,000 pages a day

Operates 6 days a week, 12 hours a day

Ensures cost savings, quality equipped with state-of-the-art scanners and technology

With our systems, automated letters can be configured to match your defined requirements. Letters can be printed on demand and/or routed to a designated print vendor for fulfillment. Triggers are in place for all CMS required pre-and post-member enrollment-related letters along with ID Card triggers, EOB, and EOP generation. Security controls such as user roles configuration and vendor access are easily configured.

Extensive reporting is essential for today’s health plans and providers. Our rapid flow of information and reporting capabilities are unmatched by our competitors.  Knowing data is the most critical component reporting, our team takes every precaution to protect it. You will receive an exclusive server or servers and a secure TP site that allows secure segregation of data and safeguards data to the highest security level.

You and your team can easily see snapshots and pull reports on the fly.  With our out-of-the box reporting features, you can stop spending valuable time configuring your own metrics and quickly create reports to fit your business needs. A full data set is always available, and users have access to pull the reports based on criteria they choose. Our systems are equipped to report on HEIDS, CAHPS, STARS, HOS, RAPS and EDPS. If your team needs additional reports, they can be added as part of the application. Our on-site, senior compliance officer monitors CMS requirements for clients and facilitate any updates needed to the system. A comprehensive logging capability that tracks all user activity throughout the system is included in our package.

The following are a few samples of our pre-configured reports:

• Claims Audit Summary Report
• Finance & Payment Check Run Statistics
• Enrollment Part D Report
• Enrollment Exception Reports
• Rollover LEP Report
• Disenrollment Count Report

Cut costs and provide better service with our Medical Management Services. Managing numerous medical treatment requests within a network is a highly complex task. Expenses of a health plan can significantly increase if there are mismanagement and ineffective care coordination. Finding a value-based approach to utilization reviews that approve the right, evidence-based treatments is critical. Additionally, managing unique cases and appeals process management through a poor provider network can put even more stress on your organization. You can simplify these processes and programs with our quality management tools., Easily provide updates from the clinical system for fundamental quality indicators and performance data, chart and site review tools, and measure patient and practitioner satisfaction.

You and your team will be able to oversee and assure the quality of care while developing appropriate utilization management of medical services and using plan resources to secure the best care.

Establish effective and efficient medical services for your members. We are managing quality care for optimal, cost-effective outcomes.

Our team and systems evaluate the medical necessity and determinants of medical services provided by participating physicians, hospitals, and other ancillary providers. We monitor capacity and performance management to safeguard against poor performance or resource abuse for costs for services.

The key to keeping cost low is due to improving member health and keeping members healthy. With our integrated techniques and commitment to attaining high member engagement, we help you stay ahead of the soaring healthcare.

Our Utilization Management Services Include:

• Prior Authorization Entry
• Evaluation Appropriateness of Medical Service(s)
• Prospective and Concurrent Claim Reviews
• Retrospective Reviews
• Disease Management
• Drug Management
• Authorization Mailings
• Case Management
  • Initial assessment of members’ health status, including condition-specific issues
  • Evaluation of available benefits
  • Development of an individualized management plan
  • Smart goals with interventions to ensure the member is working towards the goal(s)
  • Identification of barriers to meeting goals or complying with the plan
  • Development of a schedule for follow-up and communication with members
  • A process to assess progress against case management plans for members
  • Discharge Planning

HealthAxis Group has years of experience in assisting successful nation-wide TPA and employer groups. We coordinate industry-leading benefit plans administration and workflows to empower you to connect, communicate, and automate while reducing costs.

Our platform was designed to process the large transaction volumes and includes scaled options.

We deliver enterprise-wide efficiencies with end-to-end workflows for claims, encounter data, and more.

Our staff conducts all outbound education and verification (OEV) calls in a professional, efficient manner according to current guidelines – without interruption of your existing staff or greatly increasing your costs.

As a partner, we build our team to be a true extension of your business.   Our team’s training is customized for your requirements. Our staff must complete a five-week training course that includes, client-specific EOC/SOB and process flows, and scripting, along with Medicare 101, system navigation, documentation of calls, and soft skills review. Additionally, all client training materials are stored on the client-specific site for each representative to reference during a call.

We offer real-time monitoring and reporting. Our managers can quickly identify and respond to call volume by instantly seeing queued calls along with stats. CMS mandated metrics reports are provided to you on a weekly and monthly basis. Weekly call recordings are shared with you, allowing you the opportunity to oversee how well the team is servicing your members and provider.

• Hold times are less than 2 minutes
• 80% of calls are answered within 30 seconds
• Abandonment rate is less than 5%
• Call quality scores meet or exceed an average score of 97%

Our service team has achieved 5-Star Rating for our clients and can do the same for you.

We offer your organization a turn-key solution for order generation, fulfillment, tracking, and reporting. Our Over the Counter (OTC) Services make it easy for your members to receive their medications. Members can place orders via mail, phone, or internet. All call center and website integrations are tailored to meet your health plan requirements and follow CMS regulations.

All calls are answered within 30 seconds, and your members will never be placed on hold for longer than 2 minutes. All covered OTC items and the amount charged to the member benefit limit are tracked and maintained by our system. Plus, all reporting is at your fingertips.

Our solutions give members and providers the control, collaboration, and tools to be involved in the business of their healthcare organization. The result is a powerful, easy-to-use solution, built to lower costs and adjudicate claims faster and more efficiently. Our portals consist of a provider portal, a member enrollment portal, broker portal and a care management portal.

HealthAxis portals can be seamlessly integrated into your core administrative systems through our open API, giving you the tools to involve all stakeholders within your organization.

Our portals offer:

• Simple, Easy-to-use Interfaces
• Provider Director
• Appeals & Grievances
• Document Management Solutions
• Regulatory Memo Tracking
• HR Tracker
• PR Activity System
• Provider Training System

Premium billing and payments are automated through our configurable, cloud-based platform.  For adapting to the changing market, our technology provides application management capabilities and hosting services that allow for flexibility and scalability. We provide premium configuration, invoice scheduling, and payment posting for multiple lines of business under one system.

Key Features:

• Premium Configuration
• Invoice Scheduling
• Payment Posting
• Group Billings and Premiums
• Individual Billing and Premiums
• Employer and Employee Contributions
• Variable Format
• Variable Rate Calculations

Our cloud-based provider and network data management solution executes complex provider relationships, networks, facilities, and contracts with a flexible and scalable technique.

Solutions can be customized to fit your business needs giving you the ability to minimize day-to-day business disruptions.

Our provider maintenance services offer:

• Network Development
• Contract Configuration
• Provider Updates

We offer fully integrated operation through our technology enable services and commitment to keep business processing aligned with industry standards. We help healthcare providers deploy digital, analytics, and cloud-based platforms to improve patient care while recommending innovative ideas to lower costs.

Our key areas of expertise include:

• Provider Network Development & Maintenance
• Reimbursement Issues
• Communication (directories, manuals, newsletters, calls)

Revenue and risk services focus on the three main challenges of growing profitability, diminishing complexity, and controlling regulations.

Accelerate your revenue recognition and realization. Our system focuses on interoperability, which heightens the effectiveness of sales and account management.

You can mitigate risk while ensuring business continuity. Combining data analytics and visualization helps you master the business context and apply data to prevent failures, service disruptions, and revenue loss.

Through our internally managed systems, we offer Medicare Risk Adjustment (MRA) services. Our solutions continuously update to properly estimate the required dollars for each member and perform regular auditing for proper coding.

You can identify the most viable opportunities that yield the highest financial impact on the plan using complex algorithms. Our logic centers on medical history of the member, RX data, Lab data, DME usage, and CSNP eligibility of the member.

MRA Services Offered:

• Field Data Collection and Analysis
• Chart Review
• CMS Reporting

Your success starts with effective implementation. We are committed to knowing your business by closely examining and optimizing a combination of people, process, and technology. Our team guarantees your configuration is properly executed by working closely with your team to take the risk and variability out of your project.

To accommodate your growing and changing requirements, we assist in developing and maintaining tactical and strategic plans for your data center. This includes capacity planning for all aspects of the environment, benchmarking, and reporting.

Our team of experts works with you to:

• Ensure successful setup and continuous maintenance
• Setup a full configuration of plans, products, and networks
• Manage and maintain software releases and update testing
• Configure EDI transaction interfaces