Our Healthcare Consulting Services
Network Development
- Develop Medicare and Medicaid Network strategy to meet network goals and CMS and State Medicaid Network Adequacy requirements.
- Identify provider targets for outreach, contracting and gap filling.
- Negotiate contracts with hospital systems, primary and specialty care providers, IPAs, National Ancillary Services Vendors: Laboratory, Dialysis, Vision, Dental and Transportation.
- Review contract configuration
- Use Quest Analytics to access provider networks based on Medicare or Medicaid requirements
Provider Relations
- Develop Policies, Procedures and Workflows.
- Develop various educational materials for providers to promote plan, benefits, reimbursement, and billing.
- Educate Staff and provider network on Plan, benefits, reimbursement models, model of care, claims submission and payment, and problem solving.
- Credentialing requirements and reviewing CVOs.
Claims
- Develop Policies, Procedures and workflows for claims review process.
- Manage claim inventories within Medicare and Medicaid Guidelines.
- Confirm contracts are configured correctly, so claims are adjudicated correctly the first time.
- Price codes based on CMS reimbursement or State Medicaid Reimbursement.
- Claim and EDI system implementation and integration.
- Pre and Post payment integrity vendor implementation.
Utilization
- Review Primary, Specialty Care, and Ancillary Utilization: coding and unit cost.
- Review contracts for pricing, Capitation vs. actual cost, Fee for service arrangements.
- develop Specialized Programs for cost savings: incontinence and transportation.
