Optimization Services:
Maximizing Efficiency and Effectiveness
Optimization services are crucial for organizations looking to fine-tune their operations, streamline processes, and make the most of their resources. These services focus on enhancing various aspects of business, and here we'll explore five specific areas: Facets Optimization, Provider Data Cleanup/Optimization, Medicare Optimization, Data Migration, and PMO Optimization.
1. Claims System Optimization:
Claims processing is one of the most foundational core functions of a health plan and requires a very high degree of operational efficiency and effectiveness without which significant operational risks will arise. Examples of recurring challenges typically observed in claims operations are:
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Claims pend-rules that lack ongoing oversight resulting in unnecessary volume of claim-pends and customer dissatisfaction.
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Lack of sufficient understanding of the built-in system capabilities of existing claims processing platform and related components/services, resulting in a high degree of customization and manual intervention to “improvise” for features that already exist.
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Lack of process and workflow automation due to years of accumulation of manual process steps and interventions that are embedded into the daily processes with little or no transparency.
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Challenges in pre-authorization rules resulting in excessive amounts of provider appeals and dissatisfaction.
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A high degree of product customization resulting in a significant amount of maintenance and support issues.
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Challenges in managing test environments causing an excessive amount of production and critical issues resulting in negative customer satisfaction, client non-compliance and penalties.
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Insufficient oversight of operational data integrity and quality issues such as provider data (i.e. provider contracts, pricing schedules, etc.) resulting in recurring and unpredictable operational challenges and costs.
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Unaddressed issues in surrounding ecosystems negatively impacting claims processing.
This unique Proje service is a specialized form of Proje Assessment Services. It is uniquely customized for identifying operational gaps in claims processing operations (including claims platform system), and providing practical, high-value remediation actions to improve and optimize the operational effectiveness and efficiency of this critical function.
Recommended actions typically span across operational processes and workflows, business systems, tools and technologies, workforce (skills/resources), data and may include review of third party vendor challenges. Examples of these actions address challenges in areas of provider/pricing/networks, product configuration, member services, eligibility/enrollment/EDI, claims workflow, claims adjustments, claim pends, and testing.
3. Medicare Advantage Optimization:
Medicare Advantage Operations is one of the most foundational and highly regulated core functions of health plan operations. It requires a high degree of operational efficiency and effectiveness coupled with strict adherence to regulatory rules. Examples of recurring challenges typically observed that produce significant issues in operational efficiencies and effectiveness are:
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Data integrity challenges for enrollment requests coming through other brokerage firms.
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Significant volume of enrollment fallouts requiring excessive manual intervention.
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Lack of sufficient understanding of built-in system capabilities of existing Medicare Eligibility and Enrollment systems resulting in high degree of customization and manual intervention to “improvise” for features that already exist.
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Not keeping up with updates to the CMS Medicare Advantage User Guide which is the authoritative source of up-to-date protocols of interactions between CMS and a plan participating in the Medicare Advantage Program and the associated transactions sets.
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Incorrectly configured (or not configured at all) transaction sets resulting in a significant amount of transaction fallouts (errors), and/or critical data interactions not being captured and updated properly resulting in extensive amounts of manual corrections and/or questionable data trickling into claims operating system creating billing and renewal issues.
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Challenges in financial reconciliations that result in a significant over/under CMS payment scenario and remediation that follow to course correct.
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Inefficiencies in customer letter generation and fulfillment processes.
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Challenges in managing test environments that adversely impact testing and quality assurance resulting in a high degree of production and critical issues.
This unique Projé service is a specialized form of Projé Assessment Services. It is uniquely customized for identifying operational gaps in Medicare operations (including Medicare eligibility/enrollment), and providing practical, high-value remediation actions to improve and optimize the operational effectiveness and efficiency for this critical business function.
Recommended actions typically span across operational processes and workflows, tools and business systems, workforce (skills/resources), data and may include review of third party vendor challenges. Examples of these actions address challenges of insufficient process automation, gaps in online application, and brokered generated enrollment requests, gaps in end-to-end view of the eligibility/enrollment process life-cycle, lack of visibility into application process by broker community, enrollment and financial reconciliation challenges, lack of consistent and comprehensive reporting, inefficiencies in fulfillment and customer correspondence processes.
4. Data Migration:
Data migration services facilitate the smooth transfer of data from one system or platform to another. Whether a company is upgrading software, moving to a new database, or consolidating information, data migration is essential to ensure that critical data is preserved, and operations continue uninterrupted. Optimization in data migration involves minimizing downtime, maintaining data integrity, and optimizing the new data environment for improved performance.
In summary, optimization services play a vital role in helping organizations operate at their best. Whether it's fine-tuning complex software systems like Facets, cleaning up provider data, optimizing Medicare-related processes, or ensuring seamless data migration, these services are essential for enhancing efficiency, reducing costs, and achieving better outcomes. Organizations that invest in optimization services are better positioned to adapt to changing conditions, stay competitive, and deliver higher value to their stakeholders.