Risk is the front end analytics that help establish a member demographic and health risk profile to ensure sales and enrollment compliance and improve risk-adjusted reimbursement. Information captured at the front end of the process is critical to maintain regulatory compliance, avoid fines and penalties, and determine a plan’s reimbursement, directly impacting risk-adjusted premiums.
MedHOK’s Risk modules streamline the member enrollment process and enforce CMS’ regulations regarding data capture, keeping health plans in compliance using sophisticated tracking capabilities.
MedHOK combines over 1,300 proprietary and third-party certified rules and algorithms to predict, identify and target all member health risks, gaps in care and co-morbid health conditions that form the basis for risk scores and risk-adjusted reimbursement, and triggers automated workflows within the member-centric record.
MedHOK streamlines the enrollment process into Medicare Advantage, Medicare Part D Prescription Drug Plans, and Prescription Drug Plans. The enrollment functionality enforces CMS’ regulations regarding data capture and keeps Medicare Advantage/Medicare Advantage-Prescription Drug organizations and Prescription Drug Plan Sponsors in compliance using sophisticated tracking and audit capabilities.
MedHOK helps Plans resolve the data variances identified between the Plan and CMS.
Also a part of the MarketProminence product, this MedHOK module tracks member engagement and correspondence. Member service staff can view and access 360Member comprehensive profiles, based on role-based access and permissions.
MedHOK’s Complaints Tracking module (CTM) is used to process complaints about dissatisfaction with any aspect of the operations, activities, or behavior of a health plan or its providers. Customers use this solution to respond to complaints made directly to CMS by the members or representatives; provide resolution to CMS within specified timeframes; and communicate with internal and external business partners to ensure the complaint is investigated thoroughly.
Manage all grievances across the organization with this CMS-compliant structured workflow module of MedHOK. The grievances module captures all key data elements needed for the consistent processing of cases. A dashboard allows for real-time monitoring of activity by management and promotes a proactive approach to administering caseload and meeting compliance deadlines. Tracking and trending allows for early recognition of opportunities for quality improvement.
Provider Disputes is a workflow solution for processing and tracking disputes and denials from a provider with a concentrated focus on authorization and claim dispute/denial types. MedHOK offers a structured workflow based on individual user roles that ensures consistent case processing, complete effectuation, and automatic triggering of correspondence attached to the original case. The dashboard allows for real-time monitoring of activity by management and promotes a proactive approach to caseload and compliance deadlines.
MedHOK’s Risk Adjustment/RADV module offers an end-to-end risk adjustment solution aimed at accurate assessment, improvement and reporting of diagnosis-based capitation factors that drive risk score calculation systems. This facilitates efficient and effective submission of risk adjustment data and drives maximum appropriate reimbursement from Medicare and other payment agencies. Plans can conduct mock audits or prepare for CMS RADV and other audits, in addition to proactively gathering medical chart review documentation to substantiate risk score submissions.
MedHOK’s Regulatory Tracking Module consists of a Regulatory Memo Manager and a Special Investigation (SIU) Manager. The Regulatory Memo Manager is a simple and transparent solution to receive, manage, and track regulatory updates, including Health Plan Management System (HPMS) memos. The SIU Manager manages and tracks investigations of compliance incidents and potential healthcare fraud and abuse. It provides a simple way to manage workloads and timeliness via customized real-time dashboards, report issues and status to executive leadership, run reports for ad hoc and immediate reporting needs, and track Corrective Action Plans.
MedHOK’s Process Improvement/Root Cause Analysis functionality runs across the platform but are rooted in the Risk area. MedHOK is able to trace the origins of a problem so that corrective measures can be put in place to ensure future success and alleviate identified problems.
Audit all actions taken as part of the RCA to ensure all providers and outbound items were accurately and sufficiently addressed and completed.