L.A.Care
H E A LT H P L A N
Empowering the largest public health insurance entity in the United States (~$10B annually)
L.A. CARE
THE BUSINESS CHALLENGE Due to the poor quality of provider data, operating costs have risen as a result of re-work, manual effort, and fines due to lack of regulatory compliance. In addition, poor quality provider data has contributed significantly to poor service levels for providers and members alike, to the point of a degradation of care for members. L.A. Care Health Plan (LAC) lacks complete and accurate provider data, which is required to perform the following basic health plan functions:
Assign new members and reassign current members to primary care physicians (PCPs). Ensure members are able to receive care from various hospitals, practitioners and ancillary provider types based on regulatory parameters through complete visibility of the provider network and their associations. Submit provider network adequacy and other provider related data to regulatory and accreditation agencies to ensure LAC is compliant. Certify providers (18+ certifications) with a streamlined credentialing workflow. Conduct manually intensive facility site reviews for various provider facilities on different periodic schedules with active tracking of review assignment, corrective action plans (CAP), scores and status.
SOLUTION/STRATEGY These objectives are achieved through the following: Automate the intake of attested provider profile data from different provider user types, based on business rules for data quality (DQ), credentialing, FSR, and contracting. Standardize the provider profile with rules governing the golden state of provider data with certified records in a master data repository (MDM). Build credentialing and facility site review business workflows which integrate into MDM and certify provider records and facilities. Build a provider facility reviews dashboard to provide a holistic view of all current, past and upcoming reviews with assignment information which drives timely review process. Digital mobile platform to allow Nurse Practitioners to go out to field with their mobile devices and capture facility reviews, PARs and medical records data which integrates with MDM.
L.A. CARE
THE RIGHT APPROACH Provider Intake to create an effective channel for receiving provider data from authorized sources mandated by their engagement model with LA Care Provider 360 views on relationships with IPAs, Hospitals and ancillaries Workflow models to represent provider credentialing and facility site review process (FSR) Holistic dashboards for FSR scheduling on a digital platform for Nurse Coordinators and Supervisors Mobile App for Nurse Practitioners capturing field visit data on facilities and medical records review in online/offline mode
MEASURABLE BUSINESS VALUE The adoption of the PMA system will introduce the following benefits to LAC: Enhanced provider management and tracking accuracy from 65% to over 90%. Reduced turnaround time for Provider Changes by 70% with real time updates. Facility Site Reviews (FSR) digital mobile platform leading to 50% operational efficiencies across RN roles. Provider management UX creating a multi-dimensional crossfunctional view for business units on provider relationships, credentialing and intake workflows. Automated Credentialing workflows connecting to external sources for certification validations resulting in 90% scenarios as passthrough (no touch) . Timely and Accurate Provider network adequacy reporting to regulatory bodies and healthcare agencies for 100% compliance. Accurate member assignments to verified, certified and validated providers in the network creates a superior member experience.
**The Digital TaaS team is excited and proud to partner with LA Care on their digital transformation journey on the collective mission of “Elevating healthcare towards building stronger, vibrant and healthier communities"
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