Business Process as a Service for Healthcare

Membership

Loading of enrollment, eligibility, revenue, and capitation files based on health plan frequency - reconciliation and reporting duties

Encounters

Encounter processing and submission to health plans – guaranteeing network performance responsiveness

Providers

Loading and updating provider records and contract alignments to ensure accurate provider reimbursement

Health Plans

Upstream and downstream arrangements can be configured to be consistent in terms of reimbursement and carve-out structures.

Reporting

Producing timely utilization, authorization, and claims reports in standard and custom formats for health plan partners — ensuring important delegated processes are compliant

Workflow

Building and maintaining configurable rules that affect the routing of referrals, authorizations, or claims in the delegated value-based organization

Credentialing

Update data in accordance with all delegation authority and appropriate primary or secondary source verifications.

Referrals Processing

Complete utilization cycle management based on recognized medical criteria - streamline authorization process following organization's guideline policies and procedure instructions

Claims Administration

Procurement, adjudication, payment and distribution of provider and facility claims

Capitation

Ability to conduct outbound capitation payments and reconcile member reports to providers. Provide health plan usage and trending analysis to detect network leaking

Contract Negotiation

Experienced executive teams that can evaluate contracts and structures throughout the network's stakeholders, including plans, providers, specialists, facilities, and ancillaries. They are designed to help you handle issues and improve your bottom line.

Call Center Operations

Maintaining a full cycle Customer Service department capable of tracking all incoming calls, routing to suitable people, and integration with other departments such as claims and referrals for faster call resolution.