MedPOINT (MPM) utilizes multiple applications and scalable technology products across departments to establish an end-to-end workflow process. Validation rules are implemented at various stages of the automation to maximize end user efficiencies.
Core Software Applications
EZ-Cap is MedPOINT’s core medical management software tool. As one of the original purchasers of the software, MPM has continually upgraded and is now on the v 18.104.22.168 .NET version. EZ-Cap is an integrated transactional based system for performing all administrative MSO functions. The system also includes a separate capitation module. All users are assigned system security in alignment with their job functions. Our developers are constantly using the core platform to customize and enhance functionality within the MPM environment. Ongoing training is provided to end users by vendor staff and internal IT staff so that all functionality can be utilized.
MPM has built its own proprietary platform to assist with various departmental workflows and communications. Originally built to assist with the denial letter process and PDR management, the application now supports grievances/appeals, MD review process and credentialing functions. With its easy to use customizable templates, we have been able to build in mandatory workflow elements to make these processes more efficient and at the same time, meet all regulatory requirements. In addition to integration with EZ-Cap, data is pulled from other programs to create a dedicated database for.
Care Enhance Review Manager
MPM has always utilized Milliman guidelines and InterQual guidelines as the basis for outpatient (including ancillary and DME services) and inpatient review. In October 2010, we implemented the electronic version of InterQual decision making software. This provides separate modules for inpatient, outpatient, and radiology medical necessity decision making algorithms. Additionally, MPM purchased the integration license for EZ-Cap so the program seamlessly integrates with EZ-Cap’s authorization module.
Essette for Healthcare
Essette is the primary software used by our case management department. With internal and external capabilities, all communications, care plans and pertinent medical information can be located in one platform. The software also seamlessly integrates with EZ-Cap so member level eligibility, authorizations and claims can also be viewed.
MPMWeb is a proprietary secure web portal designed by MPM clinical and IT staff in conjunction with development by Goodale Systems. The portal itself has been in place for over twenty years and has undergone many enhancements. Current functionality includes processing online authorization requests with build-in client specific auto approval rules, viewing several variations of eligibility rosters, claims status lookup, claims batch upload capability, network specialty provider selection, member level care gap notifications and posted document distribution. The ability for providers to upload and view applicable attachments related to authorization requests is also available. Since the portal in developed in house, it is continually customized to align with our business rules and operational flow.
Integrated Claims Software
SymKey Professional Claims Module
SymKey provides automated claims adjudication based on specific IPA business rules. Reports are customized and built into the product to isolate various scenarios for claims adjudication. Scenarios can be generalized as identifying duplicate claims to specialized scenarios based on health plan, line of business or specific services identified on the health plan division of financial responsibility. MPM implemented SymKey during January 2010 and it has been an integral part of the claims auditing and adjudication process ever since. Although the functionality allows for greater automation, all transactions are overseen by claim management staff prior to applying the recommendations in production.
SymKey Hospital Claims Module
The same functionality described above is available for adjudicating hospital and ancillary service claims.
Image Net provides front end claims scanning which passes through several client specific business rules and edits to create a claim file to in load into EZ-Cap. The image is stored on HIPAA compliant servers and is linked to the claim residing in the system. Hot key functionality is enabled to allow real-time claim viewing.
Virtual Examiner evaluates claims for fraudulent and abusive billing as well as identifying claims for correctness in billing. There are multiple system edits that are scalable to the business rules of the IPAs. Virtual Examiner has yielded significant savings on claims costs and recoveries. MPM has used this product for five years and this year, purchased the Virtual Auto Post portion from HCIM software. This more fully automates the entire process by directly posting the Virtual Examiner adjustment reason directly in the claim rather than relying on a ‘copy and paste’ manual process.
Claims 2 EZ-Cap
This product uses DaFoDil language created by Bowman Technologies to translate electronic claims in loads into formats that EZ-Cap can accept. MPM has been using versions of this product for 20 years to create inloadable system formats that match built in system edits. The software is utilized for both individual provider files and files received from claims clearinghouses and allows more flexibility in the types of claims files we are able to accept.
Eligibility Manager, DataWing software’s flagship product, has been used at MedPOINT for over fifteen years. The product automates the reconciliation process between raw eligibility files received from contracted health plans and current eligibility data. Once the results have been audited and any adjustments made, the health plan file is directly inloaded into EZ-Cap.
Data Tug works in conjunction with Eligibility Manager to provide an automated lookup on health plan websites to identify the most current eligibility information and/or identify specific member termination data. Using this as an adjunct product for processing ‘missing member’ files after EM is reconciled has provided a further level of accuracy to refreshed eligibility files in EZ-Cap.
Cap Check, another DataWing product, provides an automated method to reconcile capitation detail files with detailed health plan eligibility files to ensure that downstream capitation was paid in accordance to the existing contract. This allows us the opportunity to do ‘real time’ reconciliations with the health plans.
IDM is an information distribution system which allows tracking of documents from the desktop. Currently, batched authorization letters are scheduled to be delivered to requested providers and member PCPs every two hours. Other provider bulletins are faxed through IDM using ‘blast fax’ type methods. End users can also e-mail a single authorization letter to providers form their desktop.
MedPOINT has used Laser Fiche back end scanning for the past fifteen years. All paper documents including administrative paperwork, authorizations and claims are stored in indexed files for immediate retrieval. Appropriate security assignments are made.
Right Fax manages business critical faxes and documents that drive our daily operations. Inbound IPA-specific faxes including authorization requests are routed to designated cues for action by the appropriate staff.
MPM is contracted with Episource in two main areas:
Chart Retrieval: Episource staff utilizes direct EMR access and other methods for remote downloads of all Medicare and Exchange files to evaluate HCC coding. Through the epiConnect portal, MPM is able to view a roadmap indicating the record collection progress and results.
Quality Platform: Interactive dashboards and reports are produced with refreshed data to assist MPM and participating providers/clinics in managed IPAs quickly identify trends in performance. The reports detail year-over-year trends, as well as comparisons to industry benchmarks which assist with developing opportunity improvement plans for the following year. Along with high level reports, member opportunity gaps in care reports are available as well to assist with member outreach efforts.
This is a Medicare risk adjustment software solution that supports improved risk adjustment scores, enhances quality ratings and helps ensure continuity of care. The online tool provides actionable reporting and other pre-populated tool to individually work with each contracted provider/clinic to improve their risk scores.