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Integrated Reimbursement

The Integrated Reimbursement solution enables health plans to reduce reimbursement administration costs and increase network performance. It automates the assembly of care teams/networks, the design and contracting of reimbursement policies, and the selection and calculation of the appropriate reimbursement for all provider services. This integrated approach drives administrative cost reduction and significantly improves provider payment accuracy. Additionally, it facilitates increased provider satisfaction through improved reimbursement transparency.

Business Challenges:

• Compliance with MLR caps
• Supporting new and more complex products, networks and care models
• Expansion of PCMHs and formation of ACOs
• Facilitating VBID and responding to VBP
• Complexity of experimenting with and long term management of hybrid reimbursement processes
• Increased complexity of managing multiple overlapping payment arrangements
• Complexity of managing and scaling alternative provider contract initiatives
• Claims inability to support reimbursement policies for new products, networks and care models

Key Features:

• End-to-end reimbursement lifecycle management
• Flexible reimbursement standards and policy design
• Agile network performance and composition modeling
• Automated contract authoring, offering, modeling, codification and loading
• English-like rules for easy pricing policy configuration
• Template-driven fee schedule & code set management
• Real-time testing of reimbursement designs
• Support for hybrid reimbursement methodologies in one reimbursement model
• Integration with MHS Contract Manager and MHS Provider Manager
• End-to-end auditing and reimbursement analytics 

Key Benefits:

• Increased compliance with MLR and administrative cost caps through decreased reimbursement administration costs
• Reduced medical expenditure and/or reduced rate of growth of medical expenditure through optimal mix of reimbursement methodologies to drive network/provider performance   
• Strengthened competitive posture through differentiated product design and performance
• Decreased provider-related claims mis-payments
• Increased provider adoption of new care and payment models