Medicare & Medicaid System Implementation

Some Medicaid plans operate within their own State managed organizational infrastructures, others outsource the hosting of their IT systems and the operations of plan administration to 3rd party Business Process Outsourcing (BPO) companies. The same is true of Medicare insurers and managed care organizations. There are benefits to both options.

ATIBA resources have the experience to lead the implementation of Medicare Information Management Systems (MIMS) or Medicaid Management Information Systems (MMIS) on behalf of insurers, ACOs or State entities. Or, we can lead project initiatives for the insurer, State or the BPO vendor when IT systems and operations are being transitioned to business process outsourcing organizations.

What exactly does all that mean? It means our team is capable in implementing, transitioning, enhancing, or upgrading Healthcare Information Systems! We understand the complexities of healthcare system integration and the importance of compliance. We are experienced in translating requirements and facilitating solution delivery and are expert in managing the development of business requirements documents (BRDs) and managing the software development lifecycle (SDLC).

The ATIBA team can ensure the implementation of policies and procedures that effectively support systems and operations, and they can ensure delivery of cohesive end-to-end processes that include provider networks, PCPs and data interfaces to 3rd party vendors such as Prime Pharmacy Benefit Managers.

We are capable in helping States implement Medicaid systems and operational processes that are designed to control administrative costs, service members and providers and satisfy federal requirements enabling them to receive 90% federal financial participation (FFP) for design, development or installation and 75% FFP for operation of state mechanized claims processing and information retrieval systems approved by CMS.

ATIBAs healthcare specialists can lead Medicare project initiatives for insurers, health plans, ACOs, or managed care organizations whose goal is to implement web-enabled information management systems that serve a critical role in the ongoing operations of Medicare Advantage (MA) and Part D programs. Allow us to assist you in delivering healthcare information management solutions that will support your operations and enhance the quality of care provided to your members!

Healthcare Plan Start-ups

The healthcare landscape is constantly evolving, enabling new health plans to initiate operations to serve populations in creative new ways. More Medicare Advantage Plans will be offered in 2019 than any year since 2009. There are currently 15 new insurers entering the market. This expansion is due to the growing numbers of Medicare beneficiaries, the flexibility health plans have to offer more and innovative supplemental benefits and the increase in the amount of government reimbursement paid to insurance companies.

New healthcare organizations may desire to introduce plans that provide solutions for various populations. These plans include Medicare Medicaid Plans (MMP) that provide integrated and coordinated Medicare and Medicaid benefits for dual eligible Medicare beneficiaries or Fully Intergraded Dual Eligible Special Needs Plans (FIDESNP) plans that provide coverage for the Dual Eligible population, and provide both Medicare and Medicaid benefits.

Or, the managed care organization may choose to promote new service area expansions for Medicare Advantage Prescription Drug (MA-PD) plans that combine health insurance benefits and prescription drug coverage in one comprehensive plan.

Regardless of the plan focus, ATIBA can provide direction, leadership and management to organizations that wish to create a new plan. Our leaders can drive new plan development and are able to seamlessly transition between strategic and operational initiatives to achieve business objectives that help you increase your revenue stream. Reach out to let us know you are interested in a free consultation on how we assist you with the development of Health Risk Assessments, Plans of Care and other tools needed to manage this high-risk population.

Medicare & Medicaid Regulatory Compliance

Adhering to regulatory compliance is a critical responsibility when working in the healthcare industry, especially when dealing with the Centers for Medicare and Medicaid Services (CMS) who mandates the rules and regulations for Medicare and, along with the states, for Medicaid healthcare plans.

For existing plans, we can help you develop an effective compliance program or validate that your current compliance program is effective. For new plans, we can assist you in developing operational models that ensure effective healthcare operations compliance.

ATIBA’s healthcare compliance leaders can help you identify areas of high risk and develop an auditing and monitoring process to manage your risk.

For example, one area of high risk that is being reviewed by CMS relates to denial of services and payments. It was noted in a recent Office of Inspector General Report that between 2014 – 2016, 75% of all appealed Medicare Advantage denials were overturned, which equated to 216,000 denials annually!

If organizations have an effective, compliant methodology in place to review and process appeals, initial decisions would not be overturned to this degree. To avoid inappropriate denials to begin with, Medicare Advantage Organizations should be conducting ‘lessons learned’ sessions; reviewing the reasons the independent review organization overturned the initial denial and taking corrective actions to avoid similar denials in the future.

Our compliance team has significant CMS audit experience and is familiar with the new CMS Audit Protocols for Medicare Advantage (MA/MAPD) Plans with or without Part D benefits and Medicare Medicaid Plans (MMP). In fact, one of our team recently participated in three State Medicare Medicaid Plan (MMP) audits and assisted with a CMS Medicare Advantage Program audit; all four audits resulted in positive outcomes!