Managed Care Organization Plans

Some common trends observed across Managed Care Organization (MCO) plans and their related entities such as clearinghouses, third party administrators, and health information exchanges are:

• Reducing costs, meeting quality and appropriateness, and efficiency of the healthcare provided
• Improved customer focus for efficient patient care
• Improved and effective utilization management to control cost of patient care
• Changing business processes such as claims administration, provider contract management, and member management
• Minimum paper work and lower out-of-pocket expenses for Managed Care consumers
• Spiraling costs of claims and pharmacy
• Demand for predictive analytics and business intelligence for various MCOs to take informed decisions
• Better disease and wellness management programs to control chronic diseases

emids with its inherent domain expertise understands various MCO plans such as:

• Accountable Care Organizations (ACOs)
• Health Maintenance Organizations (HMOs)
• Preferred Provider Organizations (PPOs)
• Exclusive Provider Organizations (EPOs)
• Point Of Service (POS)

emids understands their processes, systems, the way they operate, plans' coverage and the benefits they offer in their plans.

Our domain and technical expertise enables us to help Managed Care Organization plans with:

• Development and customization of ACO, HMO, PPO, POS, EPO provider contracting rules engine, Managed Care claims administration, utilization management, point of enrollment, member management and accounting systems
• Building Business Intelligence capabilities to Managed Care claims management systems for effective overpayment analysis and quality reporting
• Improved claims adjudication processes through our Managed Care claims adjudication specialists and their services. emids' claims adjudication automation tool quickens the process and improves productivity
• Technology migration and re-architecture of Managed Care information systems and applications

Services

• Application management and services
  emids provides application maintenance and support, system modernization and migration, and enterprise application integration services to Managed Care systems and applications - case management, reporting system, claims administration, referral, eligibility, point of enrollment and billing
• QA and testing
  emids' QA and testing services range from healthcare specific QA, and enterprise QA, to software validation to ACO, HMO, PPO, POS, EPO specific applications
• Consulting
  emids provides HIPAA 5010 and ICD 10 readiness assessment, solution design and establishing new technology strategies, as part of consulting services to ACO, HMO, PPO, POS and EPO
• BPO
  emids' domain expertise enables us to understand various Managed Care applications, systems, data, processes and their daily transactions with their related entities. This allows us to provide over-payment analysis of MCO claims, MCO member and provider enrollment, MCO claims administration, CMS validation, MCO provider license verification, and fraud & abuse management

Solutions

• HIPAA 5010 transition and business testing
  emids provides HIPAA 4010 to 5010 transition and business testing solution to ACOs, HMOs, PPOs, POS and EPOs and their applications. The solution is classified into: impact assessment services, remediation planning and implementation. HIPAA 5010 testing services include independent testing and validation. emids HIPAA business testing framework can help entities in different areas including gateways testing, Managed Care claim systems testing, trading partners testing, and validation edits
• ICD-10 transition
  emids' ICD-10 transition solution can assist MCO plans and their applications to adapt new coding standards. emids' streamlined transition solution include: consulting and impact assessment services, remediation, planning and assessment, and ICD 10 testing services
• Claims management
  emids expertise across ACOs, HMOs, PPOs, POS and EPOs enables to process Managed Care claims, overpayment analysis and QA automation. However, the claims management solution for MCOs is classified under consulting, technology and operations
• BI and analytics
  emids understands the managed care information systems and MCOs' businesses.  Our BI and Analytics solution for MCOs ranges from claims data analysis to Extraction, Transform & Loading (ETL) process of data from the MCOs and its related entities
• Interoperability
  emids' with its in-depth knowledge of interoperable standards such as HL7, DICOM, HIPAA, ICD, IHE, LOINC, SNOMED and NCPDP SCRIPT, can help ACOs, HMOs, PPOs, POS and EPOs to achieve these standards with perfection. Our interoperability solution is lined along consulting, developing and testing, maintenance and support, and training
• Mobility
  emids' domain and technology expertise enable us to develop mobile applications for payers including ACOs, HMOs, PPOs, POS and EPOs. Our mobile application development services span across Apple iPhones, Google Android and Blackberry

Benefits

• Specialized MCOs knowledge resources for implementing standards for compliance like HEDIS reporting, HIPAA EDI, ICD-10
• Integration MCO applications with healthcare exchanges and enterprise systems
• Automation in ACOs, HMOs, PPOs, POS and EPOs plans processes and systems
• Easier adoption of newer technology, leading to better patient experience
• Our tools, templates and processes accelerate the production cycle
• Readily available test scripts for varied healthcare workflows which quickens turnaround time
• Our in-depth understanding of data models and tools accelerates the development process

Case studies

• Implementation of auto adjudication tool for a leading payer
• Technology migration of claim administration product for a leading payer
• Development and QA of PoE application for a leading payer
• Migration of client data from legacy systems to new workflow-based disease management clinical platform
• PeopleSoft financials implementation and integration with an HR product for one of the largest Medicare Advantage plan

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