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Business Processing Services

Optimize your Business with a Full Range of Turnkey Services

Let our industry experience help you simplify your operations and fill any management or service gaps. Optimize member outcomes, focus on revenue, and manage risk, all while remaining compliant. Our services are built around customers and delivering first-rate experiences and results for our partners and their members. We combine the best of people, processes, and technology to help create value, drive success and efficiency for your organization by placing operational intelligence across an entire organization.

Create a service arrangement that best fits your needs, from outsourcing all plan operations to targeting single lines of services.

Appeals & Grievances

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, update appeals and grievance cases, and export logs in PDF and Excel formats. Our reporting feature includes configurable fields for all documentation supporting existing and new requirements. The weekly and monthly data reports include inventory received, timeliness of processing, amount of upheld or overturn decisions, number of dismissed and 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

Billing

Eliminate the need to hire additional resources and have the flexibility and scalability your operations need to adapt to a changing market. Our configurable, cloud-based platform automates premium billing and payments. We provide application management, 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

Compliance Consulting

Establish and cultivate a comprehensive and fully-integrated compliance program. Our
consulting services will guide you through the toughest regulations and compliance challenges.

We provide a consolidated 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.

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.

Credentialing

Quickly and easily connect with providers, validate credentials, and analyze qualifications to accelerate your workflows.

Streamline your credentialing process by eliminating your complicated, sensitive, and error-prone processes – gathering and storing provider data, performing primary source verifications, maintaining years’ worth of records, and distributing information across your organization.

Begin the credentialing process with clear onboarding communication.

  • Decrease application turnaround-time
  • Increase provider satisfaction.
  • Mass manage re-credentialing applicants
  • OIG/SAM.GOV Sanctioned Provider Review

Enrollment

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 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.

We offer:

  • 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
  • Customer service call center operations
  • Quality assurance

Fullfillment

Now more than ever, consumer expectations are driving health plan operations. Consumers want information that is easy to obtain and digest. By proactively developing outreach and account management, you increase the value for customers and ultimately raise retention. Our experienced team guides you and lessens 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 match your defined configuration 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. Plus, easily design security controls such as user roles configuration and vendor access.

Medical & Quality Management

Managing numerous medical treatment requests within a network is highly complex.
Mismanagement and ineffective care coordination can significantly increase expenses. Finding a value-based approach to utilization reviews that approve the right, evidence-based treatments is critical. You can simplify these processes and programs with our quality management tools. Effortlessly 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 can oversee and assure the quality of care while developing appropriate utilization management of medical services and using plan resources to secure the best care.

Member Services

Connect, automate, and grow your membership while reducing costs. As a partner, our team
serves as an extension of your staff, filling gaps where needed and ensuring optimal efficiency. We have years of experience in assisting successful nationwide TPA and employer groups.

Our team’s training is customized to fit your unique requirements. Staff assigned to your
account 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. On a weekly and monthly basis, you receive CMS-mandated metrics reports. Weekly call recordings are shared, allowing you to oversee how well the team is taking care of 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.

Medical Risk Adjustment

Establish effective and efficient medical services while providing quality care with cost-effective outcomes for your members.

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 costs low is having insights into your member population and keeping them healthy. With our integrated techniques and commitment to attaining high member engagement, we help you stay ahead of the soaring healthcare costs.

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

Over The Counter

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

Our team answers all calls within 30 seconds, and your members will never be 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.

Provider Services & Maintenance

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

Revenue & Risk Management

Mitigate risk while ensuring business continuity. Our revenue and risk services focus on the three main challenges- 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.

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 accurately 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 the medical history of the member- RX data, Lab data, DME usage, and the CSNP eligibility of the member.

MRA Services Offered:

  • Field Data Collection and Analysis
  • Chart Review
  • CMS Reporting
1.5+

Lives Served

97%

Customer Retention

40+

Instituting Claims
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