The Challenge:

The Affordable Care Act (ACA) gives states the opportunity to participate in a federally funded expansion of the Medicaid program, helping to cover the nation’s poorest residents. Iowa opted into the Medicaid expansion in 2014, prompting several managed care organizations (MCOs) to enter the state, which had never seen managed care before. Yet, it’s one of the most complex markets, as it delivers integrated care around medical and behavioral treatments, pharmaceuticals, community-based services, waiver programs and other offerings which the MCOs were expected to manage.

Optimity was contacted by a national MCO to assist in its new-market implementation, particularly to analyze claims data pre-payment based on new provider configuration and comprehensive services across the state’s spectrum of programs.

Following the launch, Optimity was retained to help stabilize operations, provide claims payment accuracy analytics, assist in future-state operational design, and to develop custom reports and dashboards to support the MCO’s executive leadership.

How We Helped:

Laying the groundwork and heading off potential issues

Prior to launch, Optimity performed a number of services to prepare the MCO for successful implementation. For example, we helped it define, build and implement a local model for provider networking operations. While commoditized operations could be run out of the MCO’s central office in another state, many details were market-specific. Optimity provided market-specific knowledge around local Medicaid nuances, as well as state regulations and compliance, recruiting, contracting and the support of local providers.

Once the provider network was established, we performed a comprehensive provider contract and network analysis to determine if it was properly configured. We also facilitated the proper design of benefits configuration in the plan’s system and worked to ensure proper implementation.

Prior to go-live, Optimity developed and documented business rules and state requirements to help ensure a successful market launch.

Once the program went live, Optimity investigated provider and state complaints to identify root causes of claims payment and provider configuration issues, then developed immediate- to long-term recommendations to address them. We also made it simpler for the MCO to handle operational issues through custom SQL-based reports and Excel-based dashboards.

Results/Impact:

A smoother launch and ongoing operations

Because our quality check identified $1.5 million in potential claims mispayments prior to processing, we were able to address these systemic errors before incorrect payments were made that would impact providers. From the first day of launch, the MCO achieved state compliance for paid claims, with 100% of claims paying within 14 days of receipt.

Also within the first two months after launch, we worked with the MCO to reduce denials for incorrect configuration setups by 34%. Within the same time frame, we conducted a comprehensive review of over 3,000 providers’ claim submissions to identify and correct systemic and provider-specific errors.

To ensure a seamless transition after our project was over, we provided a custom data discrepancy tool, allowing the company to perform their own analyses on their 70,000+ provider records.

With fewer potential errors in claims payments, the MCO can avoid issues affecting provider satisfaction, while robust tools and analytics enable accurate information when having conversations with the state about Medicare’s complexities.

Finally, before concluding our engagement, we assisted with change management, building a communication model to help newly established local network management and network operations teams align corporate perspectives and communicate better together.