Benchmarking Study for a Group of Claims Management Platform Vendors (MedicareMedicaid) in U.S. by Sutherland Global Services

Benchmarking Study for a Group of Claims Management Platform Vendors (Medicare/Medicaid) in U.S. May, 2013

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Peer Benchmarking for a Group of Claims Management Platform Vendors, Based on Key Platform Features (Medicare/Medicaid) Feature

TriZetto

IkaSystems

Claims Data Manager



PDE Data Management



Enrollment Administration



Financial Reconciliation Management



Risk Score Management



Special Status Management



RX Reconciliation Management



HCC Risk Management



Billing and Commissions



Capitation



Claims Processing



Customer Service

Smart Data Solutions

DST Health Solutions

Emdeon

HealthEdge

Ram Technologies



Plexis 

 



 



Plan Administration



Privacy



Provider Network Management



Membership Management



Utilization Management



HIPAA Gateway



Range of Features Exhaustive

Comprehensive

Moderate

Basic

Note: Focus of this benchmarking study has been on Vendors of Claims Management Platforms in Medicare/Medicaid space, who cater to Payers with less than 500,000 members Source: Company website, News articles, SGS Research

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Description of Benchmarked Parameters (1/2) Feature

Description

Claims Data Manager

• Claims Data Manager (CDM) assists Medicare Advantage plans in the creation of the Risk Adjustment Processing System (RAPS) file, tracking rejected data, error resolution and management reporting

PDE Data Management

• PDE Data Manager assists Medicare Advantage and Part D plans in processing the PDE submission file, Plan to Plan reconciliation, tracking rejected data, error resolution and management reporting

Enrollment Administration

• Enrollment Administration Manager (EAM) provides efficient processing of all CMS transactions from initial application through acceptance by CMS

Financial Reconciliation Management

• Financial Reconciliation Manager (FRM) assists plans to identify, track and resolve discrepancies with CMS in support of monthly CMS payment reconciliation of Medicare Advantage and Part D data

Risk Score Management

• Risk Score Manager (RSM) calculates risk scores based on a plan’s accepted RAPs data, compares your plan’s HCC scores with CMS scores and identifies discrepancies and allows the plan to report on risk adjustment trends and project revenues

Special Status Management

• Special Status Manager (SSM) automates the process of identification and submission of members who are accorded special status. These include members who have end-stage renal disease (ESRD), out of area and state/county code

RX Reconciliation Management

• Rx Reconciliation Manager (RXM) helps plans monitor reconciliation amounts against prospective bid payments for better forecasting and future bid rate development.

HCC Risk Management

• HCC Risk Adjustment Manager (HCCRAM) helps Medicare plans assess the morbidity level of each member, ensure correct and complete coding for each member, determine whether CMS risk-adjusted payments are correct based on coding and submission of documentation in support of additional diagnoses identified

Billing and Commissions

• Facets provides comprehensive features to establish and maintain the billing process. Billing activity is managed according to user-defined specifications for assigning billing levels, determining billing cycles and features, producing statements, updating accounts receivable, and reporting. Facets can administer all types of account billing, from premium rates, to volume based, to administrative services only. Facets comprehensive commissions module provides flexible configurable methods of reimbursing brokers and agents

Capitation

• Facets accommodates a variety of capitation scenarios including primary, secondary, and capitation for ancillary services, with the advantage of automatic retroactive adjustments. It supports advanced capitation contracts such as percentage of premium for government and commercial products. Risk pools and fund management can be established for all providers at risk

Claims Processing

• Facets offers a high degree of automation and data capture, with three options for reimbursement management: Claims adjudication, claims pre-pricing, and claims logging. Facets’ high degree of flexibility allows complex claims scenarios to process automatically, reducing pends and increasing first pass rates. Dental, medical, and hospital claims can be processed online or via batch processes. Facets accepts all HIPAA compliant 837 EDI transaction set claims, as well as formats using a proprietary External Claim format. Facets can be extended to the provider’s office with real time liability determination and adjudication using the Provider Point of Service Direct product

Source: SGS Research

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Description of Benchmarked Parameters (2/2) Feature

Description

Customer Service

• An advanced customer service application improves your ability to research and track inquiries from members, providers, groups, subgroups, and non-members. Because Facets is fully integrated, the customer service representative is able to access information from claims, to billing, to provider to UM, all from the customer service screens. Facets also provides powerful tools for matching members to the right provider, and capturing information pertinent to appeals and grievances

Plan Administration

• With Facets, you can handle the complex benefit structures and pricing schedules of all benefit plan types. Facets contains detailed configuration options allowing multiple options to vary all aspects of benefit design. Using Facets Guided Benefit Configuration, customers can easily create and maintain complex benefit designs

Privacy

• The solution provides functionality that addresses the administrative aspects of the federally mandated privacy regulations. The HIPAA Privacy application maintains and tracks date sensitive member privacy transactions and controls confidential communications, so you can effectively manage protected health information

Provider Network Management

• Facets simplifies the administration of complex pricing schemes for providers under multiple arrangements, captures full credentialing information, and provides the functionality you need to build a high-quality, low-cost network of providers. You can ensure more effective care by matching providers to patients and coordinating care between members, providers, and your organization. Facets also enables you to manage multiple provider relationships with health plans, including network variations, contract variations and pricing arrangements

Membership Management

• Facets provides the functionality you need to efficiently manage the administration of employer groups and individuals, and meets the growing demand for detailed information. Facets provides complete tracking of eligibility history, dependent level benefit variations and auditing capabilities

Utilization Management

• Based on extensive medical criteria, Facets brings comprehensive automation to the process of referral management, preauthorizations and case management, allowing you to manage the expense and quality of healthcare. Integration between the claims and utilization management functions allows customers to enjoy greater productivity in claims processing (higher first pass rates) and care management

HIPAA Gateway

• HIPAA Gateway incorporates the components and functionality necessary to receive, route, and store EDI transaction sets in accordance with HIPAA mandates. Use it to address your care management, customer service, revenue generation, and reimbursement management business cycles. Real-time inquiry and response transactions enable constituents to view a member’s eligibility, benefit information, and claim statuses

Source: SGS Research

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Annexure

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Detailed Qualitative Benchmarking of Claims Management Platform Vendors (1/6)

Medicare

Clients Medicaid

Smartdata Solutions

OneStream EDI Gateway

• Smart Data Solutions’ OneStream EDI Gateway provides claims management for Third Party Administrators, Medicare/Medicaid payers, physician networks, and Blue Cross/Blue Shield organizations • Smart Data’s new platform also allows for rapid, accurate analysis and reporting. Its easily-accessible web portal generates detailed data on all transactions, including more than 25 standard reports and user-programmable automated email alerts. It also provides auto-adjudication capabilities • It standardizing incoming data streams, allowing companies to process a single feed of uniformly formatted transactions

N/A

PMSI

MedicareCo • MedicareConnect provides users with multiple views of claim nnect status and associated errors • The MedicareConnect system contains an advanced library of MMSEA Section 111 regulatory business rules that are consistently reviewed and maintained by PMSI's regulatory specialists • Through PMSI's VitalPoint reporting portal, MedicareConnect users can access robust reports that provide summary and claim details throughout the lifecycle to help optimize the claims management workflow • MedicareConnect offers three tiers of claims submission options: Electronic, Hybrid and Manual • MedicareConnect has achieved a 99.9% acceptance rate on submissions to CMS

N/A

Emdeon

Emdeon Medicare Manager / DDE Plus

• AmeriChoice of New Jersey, Inc. (Medicaid NJ) • Aetna Better Health - PA Medicaid (1.3 million in 12 states) • New Jersey Medicaid • FL Medicare Part A (J9 First Coast) • NJ Medicare Part A J12 • Blue Choice Medicaid Managed Care

• A & I Benefit Plan Administrators (76,000) • AMERIGROUP Community Care of New Mexico (20,000) • Advantage by Bridgeway Health Solutions • Aetna Affordable Health Choices (SM) – SRC • AmeriHealth Administrators • Banner Health AZ (~22,000) • CIGN

S.No.

Vendor

Name of Platform

Features

• View, Prioritize, & Sort Claims by Bill Type, Reason Code, Patient Identification, & Dollar Amount • Web-based Management of Medicare Claims Inventory • Efficient Organization of Suspended, Returned to Provider, Rejected, Denied & Paid Claims • Easy Correction of Returned to Provider (T-Status) Claims • Resolution of Time-Sensitive Additional Development Requests (ADR) Documentation Issues for Suspended Claims • Real-Time, User-Friendly Access to the Common Working File • No Charge for Additional Users • Supports: Medicare

• NJ Medicare Part A J12 • Easy Choice Health Plan of New York • Medicare Home Helath & Hospice (J14 - NHIC) • Railroad Medicare (PGBA)

Commercial Blue Cross/Blue Shield Organizations

Source: SGS Research

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Detailed Qualitative Benchmarking of Claims Management Platform Vendors (2/6)

S.No. 4

Vendor CNSI

Sedgwick Claims Management Services, Inc.

Name of Platform eCAMS

JURIS System

Features

Clients Medicaid

Medicare

• CNSI’s eCAMS claims management platform provides business process-centric services, standards-based data repositories, and enhanced decision support and analytical capabilities • The eCAMS platform has a portfolio of business and technical services that enable it to support business processes more effectively • The eCAMS platform addresses system usage across a variety of stakeholders by considering the different viewpoints that business users experience from both form and function

N/A

• Medicare set-aside determination, Medicare conditional payment ("lien") negotiation and resolution, and related consulting services • The company coordinates all such services with its protocols for fulfilling the Medicare reporting obligations of clients under the Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA) • JURIS platform is a user-driven, state-of-the-art system designed to support and enhance the workflow of examiners • It offers outbound interfaces for virtually any risk management information system (RMIS) and payroll system on the market, as well as custom intake solutions • It generate automated outbound correspondence for the particular client, state, or carrier relevant to each claim • A fully automated enhancement that runs a predetermined set of criteria and best practices on a nightly basis to help drive the efficiency and results of the examiner • Sensitive medical documents and personal information never leave Sedgwick, there is no risk of breach or file corruption due to transmittal of claims to third parties

N/A

Commercial

• Louisiana Department of Health and Hospitals (DHH). (1,228,615) • The Michigan Department of Community Health • South Dakota Department of Social Services (DSS) • Maine Department of Health and Human Services (DHHS) N/A

N/A

Source: SGS Research

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Detailed Qualitative Benchmarking of Claims Management Platform Vendors (3/6)

S.No.

Vendor

Name of Platform

Features • Manages bill submission and real-time processing with Medicare’s Direct Data Entry system • Validates Medicare claims in real-time against Medicare’s fiscal intermediary and common working file • Addresses front-end and eligibility errors immediately • Accelerates the resolution, identification and management of Medicare return to provider claims • Improves workflow and accuracy, and accelerates reimbursement, routing suspended claims to biller work queues • Provides results-driven reporting to: forecast Medicare cash flow, trend cash received, determine biller effectiveness and productivity, and analyze errors and suspend reasons for trends and processing improvements • Support: Medicare

Medicare

Clients Medicaid

N/A

MedAssets

Medicare Direct Claims Mgmt

RAM Technologies

HEALTHsuite • HEALTHsuite is designed around the ANSI X12 data format, • Alameda Alliance for Health defined by HIPAA as the standard for electronic data interchange - 50,000 (Both Medicaid (EDI), and complies with all HIPAA regulations including ICD-10 and Medicare) code sets. • HEALTHsuite deploys on IBM System p servers utilizing WebSphere Application Server and DB2 Universal Relational Database Management System. Key Features: • Integrated Medical Management, Case Management, Overpayment Recovery and Subrogation capabilities • Web based application suite - access via a standard Internet Browser • No Desktop Administration • Supports: Medicaid, Medicare, Commercial, HMO, PPO, Correctional and Federal Employee products.

Plexis

Plexis Claims Manager

• Plexis Claims Manager is an integrated Microsoft SQL Serverbased healthcare information system providing complete benefit administration, medical and vision claim processing, and reporting features • Supports both Medicaid and Medicare

N/A

Commercial • • • • •

TRICARE Blue Cross Aetna Cigna UnitedHealthcare

• The Health Plan of San Mateo - Provides both Medicaid and Commercial. Members - 95,000

• Alameda Alliance - 120,000 (provides medicaid also) • The AFTRA Health & Retirement Funds

• Tuality Health Alliance 5,000 Medicaid members • VNS Choice - 7600 Medicaid members

• ColinaImperial Insurance Company • EMP Medical Services (350,000, Active-Med)

Source: SGS Research

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Detailed Qualitative Benchmarking of Claims Management Platform Vendors (4/6)

S.No.

Vendor

ikaSystems

HealthEdge

Name of Platform ikaClaims

HealthRules Medicare Module

Features • The system helps to establish benefit categories, benefit plans, payment system rules, and provider contracts • Enroll members and determine member coverage based on benefit plans, dependent eligibility, and pre-existing conditions • Establish provider/professional information according to a defined hierarchy that includes network, facility, clinic or office, and individual physician • Adjudicate claims manually or automatically via EDI • Maintain system codes, such as service codes, diagnostic codes, benefit categories, and other internal codes • Create reports and letters based on processed claims using preformatted reports and letters • ikaClaims supports commercial (group and individual), Medicare, Medicaid and Accountable care organisation (ACO) • HealthRules Medicare Module consolidates the entire process, from marketing to member retention, providing the audit controls necessary to stay in compliance and manage costs. Key Features – Enrollment, Premium billing, Payment reconciliation – CMS-compliant transaction format processing and reports – Medicare Advantage and Part D benefit plans confuration – CMS-compliant member notifications – Medicare claims pricing

Clients Medicaid

Medicare • WellMed - 100,000 members • Freedom Health - 20,000 Medicaid members

N/A

Commercial

• Total Health Care - Serves 58,000 members, including 48,000 Medicaid recipients • Total Health Choice 40,421(end of 2009)

• Parkview Health Plan Services - Healthcare provider

• Neighborhood Health Plan of Rhode Island - more than 92, 000

• Hudson Health Plan provides state-sponsored Medicaid Managed Care, Child Health Plus, and Family Health Plus insurance to 115,000 members • Seechange Health - 18,000 members

Source: SGS Research

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Detailed Qualitative Benchmarking of Claims Management Platform Vendors (5/6)

S.No.

Vendor

Name of Platform

Features

Clients Medicaid

Medicare

DST Health Solutions, LLC,

• Amisys Advance • PowerM HC • PowerM HS • PowerST EPP

• AMISYS Advance - Provides administrative solutions that manage • Health First Health Plans sophisticated processing requirements, including consumer60,000 (Both Commercial directed healthcare products. Based on HP-UX platform with an and Medicare) Oracle database, it offers scalable application server and database server. • MHC application is a fully-integrated UNIX-based health plan administration system. – MHC supports all membership enrollment functions, employer group billing, utilization management, claims processing, provider maintenance and contracting, and financial information for businesses • PowerMHS supports Large Health Insurance Carriers and Blue Cross and Blue Shield Association Plans – Its major areas includes member enrollment, member services, benefit administration, premium billing, provider management, provider reimbursement, utilization management, claims productivity, claims adjudication, financial management and reporting • PowerSTEPP supports commercial health, Medicaid, Medicare and other business lines • Support ICD-10 compliance, including both ICD-9 and ICD-10 processing.

Infocrossing Healthcare Services (A Wipro Company)

Q/Care

• Q/Care is an automated claims processing system that offers an integrated HIPAA and multi-partner electronic data interchange (EDI) solution that supports HIPAA-mandated transactions, security and privacy (including a PHI tracking tool) • Q/Care can be easily customized to specific requirements. Its inherent flexibility makes it valuable to a wide variety of healthcare payers, including managed care organizations, Medicare Advantage Plans, HMOs, Medicaid Managed Care Plans, PPOs and indemnity plans. It also enables support for dental, pharmacy and vision services • Q/Care is available under two types of contracts: Customized ASP model or a perpetual license agreement

Commercial

• MetroPlus Health Plan • Health Advantage - more 341,922 Medicaid Members than 140,000 members

N/A

Source: SGS Research

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Detailed Qualitative Benchmarking of Claims Management Platform Vendors (6/6)

S.No.

Vendor

Name of Platform

Features

Healthation

AboveHealth • • • • • • • • • • • •

HP/EDS

MetaVance Solution

Billing & Invoicing Call Center Management Contact History Contact Management Contact Scheduler Custom User Interface Customer Service Integration Customer Support Tracking Customizable Fields Customizable Functionality Customizable Reporting Data Import/Export

• The HP MetaVance Solution automates core administrative processes for a wide spectrum of commercial healthcare payers • Users of MetaVance achieve 75 to 85 percent first-pass claims processing results and save $2 per claim on average • Streamline processes and improve customer service for your employers, members, consumers and providers • Support and expedite key payer processes while supporting all HIPAA and federal regulatory requirements as well as ICD-10 processing • HP supports MetaVance on multiple platforms, including MVS, HP-UX, and Windows. • Supports support a complete array of standard and specialty including medical, hospital, outpatient, Medicare, long-term care, life/ADD, dental, CDHP and self-funded accounting arrangements

Medicare

Clients Medicaid

Commercial

• DentaQuest • MediGold

N/A

• Health Partners (140,000) • Scott & White Health Plan (202,000) • MercyCare

• Dean Health Insurance 275,000 members • Blue Cross Blue Shield of Arizona - 1.3 million members"

N/A

• Humana - 12 million members in its medical benefit plans, and 8 million members in its specialty products • Blue Cross Blue Shield of Massachusetts - 2.8 million members • Delta Dental - 59.5 million people

Source: SGS Research

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Report Concludes Here