Medical Management handles prior authorization, concurrent review, and ambulatory or complex case management activities with an overall objective to deliver timely access to health care services based on the appropriate setting (e.g., specialty, institutional).
The Utilization Management and Case Management program is designed to monitor, evaluate and manage the quality and timeliness of health care services delivered to all patients. The program provides a fair and consistent evaluation of the medical necessity delegated functions by using nationally recognized standards of practice and adopted clinical practice standards under the direction of a physician or an appropriate licensed professional.
Claims department handles claims and encounters that are the financial risk of the IPA, Capitated Hospital or Health Plan managed by Altura MSO. Our seasoned claims examiners process all lines of business including Medi-Cal, commercial, Medicare, and CalMediConnect as well as professional and institutional claims.
- We handle both paper and electronic claims, however encourage you to submit claims electronically in order to expedite processing. EZ Cap is used for claims processing with a self-proprietary application SHARE to help retrieve claim images. It communicates with various modules such ae: Authorization Module, Provider Module, and Member Module. This allows us to auto adjudicate claims when they are loaded, which decreases the turn-around-time.
- Our robust engine is used for auto adjudication from the simplistic claim to the complex claim. It is able to apply logic based on business rules that may be unique for the line of business or for the individual client.
- Other applications used to aid with the adjudication include Virtual Examiner which reviews claims for potential unbundling, duplicates, multiple procedure reductions, and claim history to determine if services are considered new or established. This too, can be adjusted to meet your needs.
- Another application, Webstrat is used for pricing and coding of inpatient and outpatient facility claims. This application also codes the APR-DRG or DRG for the services performed for the inpatient facility claim, which aids with the correct payment due to the provider and not necessarily what code was billed on the claim form.
- Given our fiduciary responsibility to our clients, we review claims prior to a check run for both payments and appropriate denials. As part of the workflow, all claims are routed to internal auditors for review prior to processing a check run. A dollar limit threshold can also be set to have claims routed to a manager prior to releasing for a check run.
- The Refund Recovery Unit reviews post payment claims for any potential refund recoveries. Examples of recovery can include, members with other health coverage and coordination of benefits needs to be conducted, overpayments based on fee schedule, members no longer eligible during the time the service was rendered, etc.
- We also coordinate with an outside vendor for third party liability for potential recoveries for the commercial and Medicare lines of business on behalf of our clients. For institutional claims processed, coordination of the review of medical records vs APR-DRG or DRG paid can be performed for any possible upcoding and recovery.
- Claims department maintains compliance with the technology and workflows in place, Altura MSO is able to meet the unique individual needs of our clients, while meeting the claims processing standards at a Federal, State, and Health Plan level.
Our Customer Support Center is responsible for providing solutions to our clients’ and providers’ inquiries by identifying and resolving issues related to patient care and services while providing exceptional customer service.
We receive and respond to incoming calls from members, member advocates, providers, and health plan representatives. Our team has friendly representatives that are available Monday through Friday from 8:00 a.m. to 6:00 p.m. Calls include but are not limited to eligibility verification, PCP updates, education on grievance and appeals, authorizations and claims status.
The Eligibility department uses Eligibility Manager to keep our clients’ eligibility up to date. Timely processing of eligibility supports all downstream processes and plays a critical role in supporting our medical management, claims payment, and physician capitation processes.
We use two state-of-the art tools, Eligibility Manager and Data Tug, to facilitate timely updates to the EZ Cap eligibility. These tools allow us to compare client, plan and line fo business specific member information against the EZ Cap system. They typically load updated eligibility for all our clients in 1-3 days from the time it is received. The eligibility team also supports research requests from Claims, Customer Support and Medical Management to ensure that inquiries from plans, providers and members are addressed in a timely manner.
Comprehensive program to monitor and evaluate quality, appropriateness and outcome of care and services.
Quality Management is achieved by:
- A focus on member-centered care and patient-provider relationships
- Emphasis on continuously improving performance in all areas
- Emphasis on efficient operational and care systems
- Use of data-driven decision making throughout the organization
Our PDM and Configuration departments ensure that providers are entered accurately, according to contract terms, and in conjunction with all applicable regulatory guidelines.
Most of our provider fee schedules use either Medicare or Medi-Cal Rates. Our automated updates from these regulatory agencies eliminates the need for data entry and potential errors and allows our claims to be paid at the government rates. The updates are put into the system as quickly as they are published by the agencies, usually the same day. This process allows our Claims department to confidently process claims and ensure that complex payment schedules will always be up to date.
Credentialing department ensures patient safety, addresses risk management concerns required by accredited and regulatory agencies. We determine an applicant’s eligibility for initial or reappointment membership/participation, analyze the application and supporting documents for completeness and inform the practitioner of the application status, including the need for any additional information. Credentialing compiles, evaluates, and presents the practitioner specific data collected and assembled during the verification process for review by one or more decision making bodies to ensure compliance with accreditation and regulatory standards.
- Altura has a structured and rigorous credentialing & re-credentialing process used to evaluate the qualifications of practitioners with whom we contract or whom we employ. This process includes a thorough and timely investigation of each practitioner’s training, experience, licensing and sanction activity, as specified by accreditation standards including without limitation those standards set by the Joint Commission on Accreditation of Health Care Organizations (TJC), Health Resource & Services Administration (HRSA), Federal Tort Claims Act (FTCA)/Centers for Medicare & Medicaid Services (CMS), Contracted Health Plans and the National Committee for Quality Assurance (NCQA).
- Re-credentialing adheres every 24 months to the day for onsite practitioners in accordance with TJC & FTCA/HRSA requirements. Practitioners who provide services offsite (non-AltaMed facilities) will be re-credentialed within 36 months in accordance with NCQA standards. Ongoing performance monitoring of sanctions will adhere during re-credentialing cycle which include member grievances/complaints adverse events.
Provider Network Management is responsible for all business related to the provider network including but not limited to provider contracting, in-services and education between the clients, provider and Altura MSO.
Provider Network Management is an integral component in maintaining the cohesiveness of our clients and contracted networks. It is extremely important to keep lines of communication open between the healthcare providers, our clients and Altura MSO. It ensures that the Provider Network is operating smoothly and efficiently. Provider Network Management works closely with all departments to assist you and your member with questions and concerns. This department addresses and resolves concerns of the providers from claims, eligibility, capitation, compliance issues and many other functions for the care of your member. Altura MSO has developed a courteous Provider Network Administration team to assist you in complying with client’s policies and procedures, health plan audits, and regulatory changes.