Gorman Health Group | Clinical
17590
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Clinical

Leading experts in Part D, Pharmacy Benefit Manager, formulary, and pharmacy programs.

Health plans must evolve Medical Management, Care Management and Quality operations into an integrated program that is adaptive or risk losing their competitive edge in the market.  In order to positively impact quality and financial outcomes, health plans must prioritize clinical capabilities as part of their goal to provide the best care to members, strengthen provider relationships, and drive overall plan performance. This is where we come in. GHG’s clinical team of licensed professionals can assess your current programs and develop integrated strategies to build a new foundation focused on compliance, quality and member centricity. Our clinical teams partner with you to maximize quality, decrease costs and strengthen revenue.

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HEDIS EVALUATION & STRATEGY

Big changes in payment rates loom for every plan and their at-risk provider networks. Uncertain where your organization stands? GHG will work with you to analyze your National Committee for Quality Assurance’s (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) data for opportunities, and identify interventions for your health plan, targeting operations, providers and/or members. From there, we will develop a winning strategy to determine applicable goals and implement an action plan. This evaluation additionally supports your organization’s overall Quality Improvement goals, metrics and performance that may be required by contract and fundamentally supports the overall success of the plan.

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MODEL OF CARE

Plans are expected to demonstrate to the Centers for Medicare & Medicaid Services (CMS) that the Model of Care (MOC) has been executed. CMS utilizes a step-by-step review of plan processes as it relates to the goals, processes, and performance outlined in the MOC. This makes NOW the time to reevaluate the structure of your current MOC for your Special Needs Plans (SNPs), as the requirements call for more than just resubmitting your previously written documents. When it comes to the MOC, is your organization asking the following questions?

 

  • What does CMS expect to see in the MOC?
  • Where do we start?
  • What should we be doing NOW to be ready for an audit?
  • Does your current MOC coincide with the requirements published?
  • Is it time to review your MOC?

 

GHG is ready to help you evaluate your current MOC to insure you have a successful submission and approval process. This evaluation includes a review of execution and ensuring you have the structure and resources to be successful, utilizing the NCQA and the Centers for Medicare and Medicaid Services (CMS) standards and audit protocol.

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MEDICAL MANAGEMENT

GHG’s team of multidisciplinary experts will work with your medical management team to evaluate your current processes through efficiency assessments and ensure effective strategies are in place across all departments. Further, we will work with your team to improve your Medical Loss Ratio (MLR) through best practices, and reduce administrative costs, while identifying areas of improvement in care management, as well as utilization management effectiveness. This may include review of the organization’s ability to succeed with NCQA health plan accreditation or certifications offered. Additionally, the GHG team can review Medical Management and applicable business units to ensure compliance with any applicable federal or state requirements.

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