Gorman Health Group | Operational Performance – Medicare
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Operational Performance

Bringing excellence to every aspect of your
implementation from enrollment to claims payment

In consideration of reduced premiums, member and provider engagement, collaboration initiatives and fierce market competition – achieving quality improvement and risk score accuracy has never been more critical to health plan competitiveness and viability.

 

At Gorman Health Group, we maintain the country’s largest staff of senior operations consultants.  Our team assists dozens of health plans every year in scrubbing their member data and can translate your business strategies into practical, efficient and rigorous work processes with the highest degree of compliance and accountability. Our exposure to so many health care organizations every year means that we have worked with virtually every software or service vendor in the space and can share with you procedural practices and audit metrics ensuring workflows are best in-class.

 

Services include:

Compliance/Audit Remediation

If you have recently identified improvements through internal auditing and put corrective actions in place, are you certain the right actions have been taken to remediate the issues found? Have measures been put in place to monitor and audit these items going forward to ensure sustainable correction? In addition to plans ferreting out their own internal deficiencies, you also have to be worried about getting “The Letter” from CMS. CMS conducts their audit and provides a list of risks and a short timeframe (ninety days) to correct the deficiencies. We can help.

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Implementation

A successful implementation requires detailed back end knowledge of CMS requirements, guidance and operational knowledge. These attributes are difficult to have readily available when you are just starting out or have the need to continue to focus on existing business. We’ll serve as your primary knowledge base and launch your start up or expansion with you. GHG staff will work with you during implementation and every step in between.

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Interim Management

If you are looking for a seasoned veteran, GHG can enhance your team with our own, providing the leadership and knowledge your organization needs to keep moving forward. If it's just a question of bandwidth, we can supplement your departments with able professionals who have years of experience providing strategic, operational, financial, and clinical services to the industry, across a full spectrum of business needs.

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Operational Assessment

Let GHG check the box in each and every operational area of your organization. Our team of veteran experts can assist in AEP preparation, transmitting of timely and accurate membership information, recommending staff levels and utilization, and maintaining and improving all enrollment processes.

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Process Improvement

Do you know your organization’s strengths and weaknesses? GHG’s team of experts will become fully immersed and embedded in your organization and assess your current business processes to ensure your workflows are best in-class.

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Reconciliation / Revenue Management

When it comes to financial reconciliation and overall membership data management, you must protect against leakage. Need help staying ahead of the CMS reconciliation process? GHG will access your member premium revenue, accounts receivable and CMS revenue reconciliation. We help you create transparency into your premium reconciliation functions and achieve accurate reimbursements from CMS.

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Root Cause Analysis

Gorman Health Group has decades of experience stress-testing hundreds of operational business units and can assist with implementing CAPs post-audit or in proactively addressing operational problems before regulators come knocking. Our comprehensive root cause analysis service focuses on every segment of your organization's value chain - we can help you address the immediate operational problem and also uncover the root cause behind it.

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