Managed Care
Friday, March 23rd, 2018

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Managed Care programs have emerged as some of the most beneficial service lines for members and
increasingly lucrative business lines for providers and payers. CareOptimize specializes in partnering
with practices looking to optimize their Managed Care contracts, workflows, and scores to
improve member results and strengthen the practice bottom line.

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CAREOPTIMIZE MANAGED
CARE SOLUTIONS

The processes, procedures, and reporting required to maximize a managed care plan vary
greatly from practice to practice, based on location, panel makeup, current contracts in place, EHR
capabilities, coding habits, and alignment on the value-based care continuum. CareOptimize clients
benefit from our customized managed care solutions portfolio that includes:

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HCC Coding

Hierarchical Conditional Category – Diagnosis codes selected by CMS that are used to create a patient’s risk (RAF) score and correlating reimbursement amount. Improve reimbursement by incorporating the documentation of HCCs into your workflow, based off accurate risk scores.

    • Training to identify & appropriately select HCC codes – sourced from current provider, specialists, hospital discharge summaries, lab results and diagnostic results.

    • Point of care HCC coding guidance.

    • Coding review processes between providers and coders prior to claim creation.

    • Custom extractions from additional sources sent to payers.

    • Shows claim and reporting data imported into the EHR.

    • Identification of suspected codes.

    • Alerts user to overdue codes and drop-offs.

    • Reports tracking provider utilization.

    • Post visit coder training – review chart notes to ensure relevant HCCs were documented during the visit, were coded to the highest level, and have a corresponding plan of care.

[/vc_column][/vc_row][vc_row type=”full_width_content” full_screen_row_position=”middle” equal_height=”yes” bg_color=”#f3f3f3″ scene_position=”center” text_color=”dark” text_align=”left” top_padding=”60″ bottom_padding=”60″ class=”columna-2″ id=”columna-30-info-derecha-4-mobile-ocultar” disable_element=”yes” overlay_strength=”0.3″][vc_column column_padding=”no-extra-padding” column_padding_position=”all” background_color_opacity=”1″ background_hover_color_opacity=”1″ column_shadow=”none” width=”1/2″ tablet_text_alignment=”default” phone_text_alignment=”default” column_border_width=”none” column_border_style=”solid”][image_with_animation image_url=”977″ alignment=”right” animation=”None” box_shadow=”none” max_width=”100%”][/vc_column][vc_column column_padding=”no-extra-padding” column_padding_position=”all” background_color_opacity=”1″ background_hover_color_opacity=”1″ column_shadow=”none” width=”1/2″ tablet_text_alignment=”default” phone_text_alignment=”default” column_border_width=”none” column_border_style=”solid”]

HCC Coding

Hierarchical Conditional Category – Diagnosis codes selected by CMS that are used to create a patient’s risk (RAF) score and correlating reimbursement amount. Improve reimbursement by incorporating the documentation of HCCs into your workflow, based off accurate risk scores.

    • Training to identify & appropriately select HCC codes – sourced from current provider, specialists, hospital discharge summaries, lab results and diagnostic results.

    • Point of care HCC coding guidance.

    • Coding review processes between providers and coders prior to claim creation.

    • Custom extractions from additional sources sent to payers.

    • Shows claim and reporting data imported into the EHR.

    • Identification of suspected codes.

    • Alerts user to overdue codes and drop-offs.

    • Reports tracking provider utilization.

    • Post visit coder training – review chart notes to ensure relevant HCCs were documented during the visit, were coded to the highest level, and have a corresponding plan of care.

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HCC Coding

Hierarchical Conditional Category – Diagnosis codes selected by CMS that are used to create a patient’s risk (RAF) score and correlating reimbursement amount. Improve reimbursement by incorporating the documentation of HCCs into your workflow, based off accurate risk scores.

    • Training to identify & appropriately select HCC codes – sourced from current provider, specialists, hospital discharge summaries, lab results and diagnostic results.

    • Point of care HCC coding guidance.

    • Coding review processes between providers and coders prior to claim creation.

    • Custom extractions from additional sources sent to payers.

    • Shows claim and reporting data imported into the EHR.

    • Identification of suspected codes.

    • Alerts user to overdue codes and drop-offs.

    • Reports tracking provider utilization.

    • Post visit coder training – review chart notes to ensure relevant HCCs were documented during the visit, were coded to the highest level, and have a corresponding plan of care.

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Managed Care Readiness Assessment

CareOptimize starts by understanding your unique practice, location, providers, and patients. By reviewing your existing areas below, we develop a roadmap for your practice to optimize its managed care offering.

    • Payer agreements

    • Current workflows

    • Coding processes

    • Improved revenue potential

CareOptimize bases its managed care consulting services off our proven track record of not only dramatically boosting the bottom line, but also improving member results.

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Managed Care Readiness Assessment

CareOptimize starts by understanding your unique practice, location, providers, and patients. By reviewing your existing areas below, we develop a roadmap for your practice to optimize its managed care offering.

    • Payer agreements

    • Current workflows

    • Coding processes

    • Improved revenue potential

CareOptimize bases its managed care consulting services off our proven track record of not only dramatically boosting the bottom line, but also improving member results.

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HCC Coding

Hierarchical Conditional Category - Diagnosis codes selected by CMS that are used to create a patient’s risk (RAF) score and correlating reimbursement amount. Improve reimbursement by incorporating the documentation of HCCs into your workflow, based off accurate risk scores.

    • Training to identify & appropriately select HCC codes - sourced from current provider, specialists, hospital discharge summaries, lab results and diagnostic results.

    • Point of care HCC coding guidance

    • Coding review processes between providers and coders prior to claim creation

    • Custom extractions from additional sources sent to payers

    • CareOptimize HCC Templates:
      Training to identify suspected codes, overdue codes, and drop-offs. Reports tracking provider utilization. Best practices in tracking provider utilization.

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HCC Coding

Hierarchical Conditional Category - Diagnosis codes selected by CMS that are used to create a patient’s risk (RAF) score and correlating reimbursement amount. Improve reimbursement by incorporating the documentation of HCCs into your workflow, based off accurate risk scores.

    • Training to identify & appropriately select HCC codes - sourced from current provider, specialists, hospital discharge summaries, lab results and diagnostic results.

    • Point of care HCC coding guidance

    • Coding review processes between providers and coders prior to claim creation

    • Custom extractions from additional sources sent to payers

    • Training to identify suspected codes, overdue codes, and drop-offs.

    • Best Practices in tracking provider utilization

    • CareOptimize HCC EHR templates

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Medicare Advantage Overlay

After years of witnessing practices being forced to use inadequate workflows and templates, CareOptimize has created the managed care EHR Overlay/Template to help manage a more efficient process. Our overlay simplifies your Medicare Advantage workflow by:

    • Including your EHR problem list.

    • Pulling outside specialist claims data.

    • Importing hospital claims.

    • Providing your CMS monthly output report.

    • Identifying suspected conditions to improve your coding.

    • Recommending appropriate diagnosis codes in real time.

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Medicare Advantage Overlay

After years of witnessing practices being forced to use inadequate workflows and templates, CareOptimize has created the managed care EHR Overlay/Template to help manage a more efficient process. Our overlay simplifies your Medicare Advantage workflow by:

    • Including your EHR problem list.

    • Pulling outside specialist claims data.

    • Importing hospital claims.

    • Providing your CMS monthly output report.

    • Identifying suspected conditions to improve your coding.

    • Recommending appropriate diagnosis codes in real time.

[/vc_column][/vc_row][vc_row type=”full_width_content” full_screen_row_position=”middle” equal_height=”yes” bg_color=”#f3f3f3″ scene_position=”center” text_color=”dark” text_align=”left” top_padding=”60″ bottom_padding=”60″ class=”columna-2″ id=”columna-30-info-derecha-2″ overlay_strength=”0.3″][vc_column column_padding=”no-extra-padding” column_padding_position=”all” background_color_opacity=”1″ background_hover_color_opacity=”1″ column_shadow=”none” width=”1/2″ tablet_text_alignment=”default” phone_text_alignment=”default” column_border_width=”none” column_border_style=”solid”][image_with_animation image_url=”1281″ alignment=”right” animation=”None” box_shadow=”none” max_width=”100%”][/vc_column][vc_column column_padding=”no-extra-padding” column_padding_position=”all” background_color_opacity=”1″ background_hover_color_opacity=”1″ column_shadow=”none” width=”1/2″ tablet_text_alignment=”default” phone_text_alignment=”default” column_border_width=”none” column_border_style=”solid”]

Medicare Advantage Overlay

After years of witnessing practices being forced to use inadequate workflows and templates, CareOptimize has created the managed care EHR Overlay/Template to help manage a more efficient process. Our overlay simplifies your Medicare Advantage workflow by:

    • Including your EHR problem list.

    • Pulling outside specialist claims data.

    • Importing hospital claims.

    • Providing your CMS monthly output report.

    • Identifying suspected conditions to improve your coding.

    • Recommending appropriate diagnosis codes in real time.

[/vc_column][/vc_row][vc_row type=”full_width_content” full_screen_row_position=”middle” equal_height=”yes” bg_color=”#f3f3f3″ scene_position=”center” text_color=”dark” text_align=”left” top_padding=”60″ bottom_padding=”60″ class=”columna-2″ id=”columna-30-info-derecha-4-mobile-ocultar” overlay_strength=”0.3″][vc_column column_padding=”no-extra-padding” column_padding_position=”all” background_color_opacity=”1″ background_hover_color_opacity=”1″ column_shadow=”none” width=”1/2″ tablet_text_alignment=”default” phone_text_alignment=”default” column_border_width=”none” column_border_style=”solid”][image_with_animation image_url=”992″ alignment=”right” animation=”None” box_shadow=”none” max_width=”100%”][/vc_column][vc_column column_padding=”no-extra-padding” column_padding_position=”all” background_color_opacity=”1″ background_hover_color_opacity=”1″ column_shadow=”none” width=”1/2″ tablet_text_alignment=”default” phone_text_alignment=”default” column_border_width=”none” column_border_style=”solid”]

STAR Ratings

This quality rating system was created by CMS to show how well managed care plans, like Medicare Advantage, provide care to their members (from 1 Star to 5 Stars). Higher STAR ratings result in bonus payments, greater marketing flexibility, and increased open enrollment periods. Ratings are based on 5 categories that CareOptimize helps practices improve.

    • Preventative Care Measures – Screenings, tests, vaccines, etc.

    • Chronic Condition Management.

    • Plan Responsiveness & Care.

    • Member Satisfaction and Complaint Resolution.

    • Health Plan Customer Service.

CareOptimize has successfully achieved 5 Stars for multiple clients, not only allowing for these groups to enroll more members, but also improve their reimbursement amounts and bonuses.

[/vc_column][/vc_row][vc_row type=”full_width_content” full_screen_row_position=”middle” equal_height=”yes” bg_color=”#f3f3f3″ scene_position=”center” text_color=”dark” text_align=”left” top_padding=”60″ bottom_padding=”60″ class=”columna-2″ id=”columna-30-contenido-3-derecho” overlay_strength=”0.3″][vc_column column_padding=”no-extra-padding” column_padding_position=”all” background_color_opacity=”1″ background_hover_color_opacity=”1″ column_shadow=”none” el_class=”img-izquierda-box-3-desk” width=”1/2″ tablet_text_alignment=”default” phone_text_alignment=”default” column_border_width=”none” column_border_style=”solid”]

STAR Ratings

This quality rating system was created by CMS to show how well managed care plans, like Medicare Advantage, provide care to their members (from 1 Star to 5 Stars). Higher STAR ratings result in bonus payments, greater marketing flexibility, and increased open enrollment periods. Ratings are based on 5 categories that CareOptimize helps practices improve.

    • Preventative Care Measures – Screenings, tests, vaccines, etc.

    • Chronic Condition Management.

    • Plan Responsiveness & Care.

    • Member Satisfaction and Complaint Resolution.

    • Health Plan Customer Service.

CareOptimize has successfully achieved 5 Stars for multiple clients, not only allowing for these groups to enroll more members, but also improve their reimbursement amounts and bonuses.

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Patient Experience Improvement (a)

Enabling managed care members to thrive under your practice’s programs is the goal of CareOptimize. Implementing the appropriate patient related processes is the cornerstone to not only growing your managed care member network, but also ensuring that your members are receiving services that surpass expectation.

    • Member Communication – utilizing proper channels and frequency of outreach.

    • Educational Access – providing guidance outside the walls of your practice.

    • Services Offered – the ideal balance based upon your practice strengths, member demographics, competition, member expectation, and cost.

    • Patient Activation – strategies moving your members towards managing their health.

[/vc_column][/vc_row][vc_row type=”full_width_content” full_screen_row_position=”middle” equal_height=”yes” bg_color=”#f3f3f3″ scene_position=”center” text_color=”dark” text_align=”left” top_padding=”60″ bottom_padding=”60″ class=”columna-2″ id=”columna-30-info-derecha-4-desk” overlay_strength=”0.3″][vc_column column_padding=”no-extra-padding” column_padding_position=”all” background_color_opacity=”1″ background_hover_color_opacity=”1″ column_shadow=”none” width=”1/2″ tablet_text_alignment=”default” phone_text_alignment=”default” column_border_width=”none” column_border_style=”solid”][image_with_animation image_url=”1258″ alignment=”” animation=”None” box_shadow=”none” max_width=”100%” el_class=”img-desk-izquierda-4″][/vc_column][vc_column column_padding=”no-extra-padding” column_padding_position=”all” background_color_opacity=”1″ background_hover_color_opacity=”1″ column_shadow=”none” el_class=”info-desk-izquierda-4″ width=”1/2″ tablet_text_alignment=”default” phone_text_alignment=”default” column_border_width=”none” column_border_style=”solid”]

Patient Experience Improvement (b)

Enabling managed care members to thrive under your practice’s programs is the goal of CareOptimize. Implementing the appropriate patient related processes is the cornerstone to not only growing your managed care member network, but also ensuring that your members are receiving services that surpass expectation.

    • Member Communication – utilizing proper channels and frequency of outreach.

    • Educational Access – providing guidance outside the walls of your practice.

    • Services Offered – the ideal balance based upon your practice strengths, member demographics, competition, member expectation, and cost.

    • Patient Activation – strategies moving your members towards managing their health.

[/vc_column][/vc_row][vc_row type=”full_width_content” full_screen_row_position=”middle” equal_height=”yes” bg_color=”#f3f3f3″ scene_position=”center” text_color=”dark” text_align=”left” top_padding=”60″ bottom_padding=”60″ class=”columna-2″ id=”columna-30-ocular-desk-5″ overlay_strength=”0.3″][vc_column column_padding=”no-extra-padding” column_padding_position=”all” background_color_opacity=”1″ background_hover_color_opacity=”1″ column_shadow=”none” width=”1/2″ tablet_text_alignment=”default” phone_text_alignment=”default” column_border_width=”none” column_border_style=”solid”][image_with_animation image_url=”1256″ alignment=”right” animation=”None” box_shadow=”none” max_width=”100%”][/vc_column][vc_column column_padding=”no-extra-padding” column_padding_position=”all” background_color_opacity=”1″ background_hover_color_opacity=”1″ column_shadow=”none” width=”1/2″ tablet_text_alignment=”default” phone_text_alignment=”default” column_border_width=”none” column_border_style=”solid”]

Ongoing Support, Customization, and Training

The CareOptimize team knows first-hand what is required to stay on top of the annual changes in managed care programs. That’s why we offer a flat fee pricing model, so you never have to worry about feeling nickeled and dimed when your practice needs to adapt, CareOptimize has you covered.

    • Regulatory Updates.

    • EHR Customizations.

    • Practice/Provider Reporting.

    • Workflow Enhancements.

    • Coding Training.

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Ongoing Support, Customization, and Training

The CareOptimize team knows first-hand what is required to stay on top of the annual changes in managed care programs. That’s why we offer a flat fee pricing model, so you never have to worry about feeling nickeled and dimed when your practice needs to adapt, CareOptimize has you covered.

    • Regulatory Updates.

    • EHR Customizations.

    • Practice/Provider Reporting.

    • Workflow Enhancements.

    • Coding Training.

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THE CAREOPTIMIZE ADVANTAGE

Most EHRs and consultants can only talk about managed care from the outside looking in.
CareOptimize however, has the unique distinction of working hand-in-hand with CareMax Medical
Centers, 7 Medicare Advantage, full service, full-risk, clinics. With the financial well-being of your practice
and your patients’ care on the line, you deserve a partner who lives and breathes not just managed
care day in and day out, but who has successfully transitioned groups through the full value-based continuum.

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OUR RESULTS INCLUDE

5 STAR ratings
1.9 average RAF (risk) scores
Member increase of 56%
25% improvement of gross member premium

Expanded in-house services that include:

  • Primary Care
  • Gastroenterology
  • Optical
  • Pain Management
  • Fitness Classes
  • Pharmacy
  • Transportation
  • Social Services
  • Cardiology
  • Diagnostic
  • Lab Services
  • Dental
  • Podiatry
  • Spa Services
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CONTACT US

    Your Message
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