MANAGEMED MANAGED CARE

CySolutions realizes the health care claim business is an industry in consolidation. Competition is forcing companies like yours to increase productivity and expand operations to draw new sources of revenue. Through superior technology, ManageMed meets this challenge by offering the most sophisticated and complete eligibility, utilization management, and claim processing product available.

• Preferred Provider Organizations (PPO)
• Third Party Administrators (TPA)
• Independent Physician Organizations (IPO, IPA)
• Health Maintenance Organizations (HMO)
• Managed Care Organizations
• Self Insured Employer Groups

Eligibility
ManageMed has a complete system to maintain patient eligibility history and report electronic information received from healthcare payors and HMO's to the provider constituency. The eligibility information can also be reconciled to capitation and other revenue information and can be accessed by member organizations through an interface to the host website of the provider organization, all within the requirements for patient privacy dictated by HIPAA.

Utilization
ManageMed can track the activities of review nurses as they interact as agents of the payer to monitor provider services as applied to specific episodes of care. Activities include Large Case Management, Utilization Review, Referrals, and Pre-Certifications or Authorizations. The case management subsystem collects claim and clinical data by episode and tracks the cumulative claim dollars and quantities required in many plan definitions. The system also tracks inpatient activity and provides reports for use in reconciling revenue sharing arrangements with inpatient facilities.

The Case Management subsystem is tightly integrated with our repricing and adjudication systems. It can automatically detect and control the repricing and payment of claims down to the level of specific services for specific providers.

Claims Adjudication and EDI
ManageMed was designed to completely automate claims flow. Our rules-based benefit logic engine, looks at dated pre-certifications and authorizations matching them to claims along with applicable member co-pays, coinsurance, deductibles, life-time maximums, out-of-pockets, plan year-to-date values, etc. to determine benefit amounts. Service encounters, withheld amounts, penalty situations, as well as unlimited benefit definitions are all handled through this system. ManageMed provides payers with means to completely delineate any plan of benefits and apply different contracting scenarios to each provider. Letters of Agreement for non-contracted providers are also efficiently tracked and handled.

ManageMed supports EDI processing of HCFA and UB92 claims. Data transmission formats that are currently implemented include NEIC/ENVOY HCFA, as well as complete HCFA, UB92 and other proprietary formats. CySolutions will map to EDI formats required by its clients. ANSI 837 and 835 formats for claims and remittance will also be available by HIPAA deadline dates.

Claims can go from EDI input to EDI output (and/or a pricing sheet, check or EOB) without any intervention from an examiner. Powerful search engines find provider and patient records while sophisticated algorithms automate the network and product selection process. Where EDI claims are entered without being seen by a person, ManageMed provides filters questionable claims, updates the message system, and identifies all exceptions that may occur during processing for subsequent error correction resolution. This is handled through our user-driven Code Sentinel™ application where rules can be established to flag suspect procedures and diagnoses for review. For example, if a clinic's billing company sends an EDI claim with a pap smear on a 60-year-old male, it will be routed to a claims examiner for appropriate review.

Reporting
ManageMed reporting is simple and flexible. In contrast to other systems, very few reports are hard coded into ManageMed. Instead, CySolutions has developed an external application integration system. All types of reports are available through the use of common reporting tools such as Crystal Reports®, Microsoft Access®, Microsoft Word®, and Microsoft Excel®. These well known programs can create reports from any combination of the thousands of fields found in ManageMed's data records.

Although ManageMed comes with approximately 100 "canned" reports, external application integration allows each user to develop the exact content and graphical layout desired for their data. Each report is launched directly from the ManageMed menu, so there is no need to leave ManageMed to call these other applications. Application integration reports can be scheduled to run at a time of your choosing, at night or on the fly.

Any information captured in ManageMed can be used to generate a report.

If you would like to know more about our solutions and services, you can reach us by phone or email and we can talk about your business and how ManageMed can help.