Affiliation opportunities to participate in favorable global-risk contracts

Analysis of risk-taking potential via physician/practice comprehensive evaluation assessment

Network development of PCP, specialist, ancillary, and facility providers

Contract analysis, review, and recommendations (Specifically, Medicare risk contracts)

Monthly/Quarterly MCO settlement review

Funding /Claims analysis

AAPCC funding review and reconciliation

Medicare Risk Adjustment (MRA) analysis to optimize funding based on patient population, severity diagnosis and acuity level.

IBNR analysis to ensure consistency and uniformity in MCO chosen methodology

Assigned membership accretion and deletion review to scrutinize for unreconciled or omitted member funding

PM/PM claims expense peer comparison (retrospective and concurrent)

Specialist, ancillary, and facility rates analysis

In-depth hospital and skilled nursing home contracts and claims review

Identifying overpayments, erroneously processed claims, and high-cost claims trends

On staff nursing personnel available with over 15 years of HMO experience

Coverage and benefits interpretation assistance and guidance

CMS-approved CHF/CAD disease management program

Utilization Review (UR) and Utilization Management (UM)

On-site hospital and SNF visits for catastrophic/complex cases

Assistance with Hospital/SNF discharge planning

Liaison for out-of-area hospitalizations

Pharmacy cost-savings analysis (oral, injectables, chemo, etc.)

Access to specialized category indicators (i.e., Hospice, dual-eligible Medicaid Medicare, ESRD, Institutional/Custodial)

Real-time MCO data conversion

Access to proprietary software to analyze and review funding/claims data

EDI capabilities for a multiplicity of inquiry, submission, and reporting functions

MRA software tools available for reviewing and capturing all appropriate funding increases as allowed by CMS