Medicare Advantage

Medicare Advantage plans (also known as "Medicare Part C") and their related entities such as clearinghouses, third party administrators, and health information exchanges are witnessing various trends and changes across Medicare Advantage plans.

Changing regulations such as HIPAA 5010, ICD-10 and stringent reporting; changing business processes such as claims administration, benefit management, contract management, member management and disease/ wellness management; demand for predictive analytics and business intelligence are some common trends that are observed across Medicare Advantage plans.

emids, by the virtue of its domain expertise, understands various processes and systems in Medicare Part A (hospital insurance), Medicare Part B (medical insurance) and Medicare Part D (Medicare prescription drug coverage)that are included in Medicare Advantage plan, the way they operate, provide benefits and also the coverage.

emids, currently partners with Medicare Advantage plans, helping them with:

• Development of "Point of Enrollment" application
• Implementation of auto adjudication tool to automate their claims adjudication process
• Migration of their legacy application to PeopleSoft financials and integration of the same with their Human Resource application

Services

• Application management services(AMS)
  emids provides application maintenance and support, system modernization and migration, and enterprise application integration services to their applications such as claims administration, point of enrollment, care management, provider and member management,  prescription drug coverage, CRM, and disease/ wellness management, as part of AMS
• QA and testing
  emids provides, software validation, enterprise QA, specialized testing and healthcare specific QA to prescription drug coverage, point of enrollment claims administration, care management, provider and member management, and disease/ wellness management applications
• Consulting
  emids provides HIPAA 5010 and ICD 10 readiness assessment, and solution design and establishing new technology strategies, as part of consulting services
• BPO
  emids BPO services to Medicare Advantage plans manages increased volumes of over payment analysis, member and provider enrollment, healthcare claims administration, provider and member management, CMS validation, provider license verification, and fraud & abuse management

Solutions

• HIPAA 5010 transition and business testing
  emids provides HIPAA 4010 to 5010 transition and business testing solution to Medicare Advantage plans and their applications. The solution is classified into: impact assessment services, remediation planning and implementation, and HIPAA 5010 testing services including independent testing and validation. emids HIPAA business testing framework can help entities in different areas including gateways testing, claim systems testing, trading partners testing, and validation edits 
• ICD-10 transition
  emids' ICD-10 transition solution can assist Medicare Advantage plans and their applications to adapt new coding standards. emids' streamlined transition solution includes: consulting and impact assessment services, remediation, planning and assessment, and ICD 10 testing services
• Claims management
  emids' expertise around Medicare Advantage plans has enabled us to provide revenue cycle management, health insurance claims processing, overpayment analysis and QA automation. However, the claims management solution is classified under consulting, technology and operations
• BI and analytics
  Having understood the Medicare Advantage plans and their businesses, emids offers end to end BI/ DW and Analytics solutions. The solution ranges from claims data analysis and mining, to Extraction, Transform & Loading (ETL) process of data from the plan and its related entities
• Interoperability
  emids' with its in-depth knowledge of interoperable standards such as HL7, DICOM, HIPAA, ICD, IHE, LOINC, SNOMED and NCPDP SCRIPT, can help Medicare Advantage plans to achieve these standards with perfection. Our interoperability solution is lined along consulting, developing and testing, maintenance and support, and training
• Mobility
  emids' domain and technology expertise enable us to develop mobile applications for payers including Medicare Advantage plans. Our mobile application development services span across Apple iPhones, Google Android and Blackberry

Benefits

• Automation in Medicare Advantage plan's processes and systems
• Specialized healthcare knowledge resources for implementing standards for compliance like meaningful use, HEDIS reporting, HIPAA EDI, ICD-10
• Integration with healthcare exchanges and enterprise systems
• Easier adoption of newer technology, leading to better patient experience
• Our tools, templates and processes accelerate the production cycle
• Readily available test scripts for varied healthcare workflows which quickens turnaround time
• Our in-depth understanding of data models and tools accelerates the development process

Case studies

• Development and QA of PoE application for a leading payer
• Implementation of auto adjudication tool for a leading payer
• PeopleSoft financials implementation and integration with an HR product for one of the largest Medicare Advantage plan
• Technology migration of claim administration product for a leading payer
• Build, test, and operate an automated erroneous claims detection system for a US top-3 insurance processor
• Migration of client data from legacy systems to new workflow-based disease management clinical platform

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