Benefits of Population Health Management

Membership

Routinely load enrollment, eligibility, revenue, or capitation files based on health plan frequency; complete reconciliation and report.

Encounters

Encounter processing and health plan submission - assuring timeliness

Providers

Loading and updating provider information and contracts ensures correct provider reimbursement.

Health Plans

Configuration of current or new health plan agreements, payment and carve-out structures or procedures with network and out-of-network provider organizations, providing uniform upstream and downstream structure.

Reporting

Generating timely utilization, authorization, and claims report formats required by health plan partners – assuring compliance with important delegated processes

Workflow

Building and maintaining each customizable rule that affects the routing or approval, denial, and pend procedures of referrals, authorizations, or claims in the delegated value-based organization.

Credentialing

Full provider profiles and triggers to keep data updated – compliance with all delegated authorities, updating through primary or secondary source verifications

Referrals Processing

Manage the whole use cycle based on accepted medical criteria, simplifying the authorization process per organization guidelines.

Claims Administration

Processing and adjudication of provider and facility claims, including payment and distribution.

Capitation

Ability to manage outbound capitation payments and provider reports. Trend health plan usage to identify network leakage.

Contract Negotiation

Experienced executive teams who can review contracts and arrangements for all network stakeholders, including plans, providers, specialists, facilities, and supplementary services. They're meant to work on your behalf to improve your bottom line.

Call Center Operations

Full-cycle Customer Service department with capacity to log all inbound questions, route to relevant staff, and integrate with suitable department structures such as claims and referrals for faster call solutioning and resolutions.