SaaS application connects provider contract and member enrollment details for real-time authorizations and referrals, eliminates costs and delays tied to manual utilization management and universe creation
DALLAS, TX – August 8, 2018 – Medecision, the leader in population health and care management solutions, announced today it has launched a new SaaS application, Aerial UM Connector™, that automates authorizations and referrals in order to drive compliance and reduce costs for health plans and TPAs with substantial Medicare and Medicaid populations. The new app ensures regulatory compliance and reduces out-of-network referrals by connecting provider contract details with member enrollment details, presenting care managers with real-time, context-relevant information that increases provider and member satisfaction by improving care delivery.
“Many of our clients manage complex populations with tens of millions of lives, so proactively guiding members to in-network providers is critical to controlling costs,” said Deborah Gage, President and CEO at Medecision. “Conservatively, an out-of-network office visit costs $20 more than an in-network visit. If 20 percent of annual office visits are out-of-network and we can convert half of them to in-network, based on average reimbursement and utilization rates, we estimate that our clients can save close to $4 PMPY for just one ICD-10 code. When you also consider the operational and labor cost savings, the ROI quickly reaches 10x.”
In addition to costs related to non- or low-automation of utilization management, the Centers for Medicare and Medicaid Services (CMS) imposes millions of dollars each year in civil money penalties on healthcare organizations due to incorrect documentation and missed or unrequested authorizations, often stemming from manual, cumbersome processes. This year CMS is on track to assess the highest rate of penalties since 2014.
How It Works
Aerial UM Connector connects provider/member details and verifies requests are complete and accurate before submission. Most requests can be auto-approved, allowing care managers to focus on authorizations for high-cost services, drugs or procedures to ensure the right level of care for at-risk patients. Government health plans experience these benefits:
- Lower out-of-network costs: When a provider submits a referral request, Aerial UM Connector limits available choices to in-network providers for the member, along with associated cost savings. If there are no in-network matches for the member, via configured rules, the provider can be prompted to immediately request an exception, reducing cycle time.
- Streamlined workflow: Aerial UM Connector also displays only the fields, code sets, and criteria relevant to the authorization type (pharmacy, emergency transportation, etc.). Removing thousands of extraneous authorization fields enables providers to improve request accuracy and efficiency by up to 50 percent. Health plans will now have a direct connection to provider networks, preventing delays and costs associated with manual authorizations, and improving the member experience.
- CMS compliance: By meeting CMS reporting requirements, including documentation of denials and turnaround times, Aerial UM Connector helps health plans accurately report universes, reduce the volume of appeals and grievances, and prevent audit penalties. Evidence-based rules and criteria sets are easily configured to help mitigate risk around CMS-defined challenges such as appropriate levels of care, opioid medication management, and certain social determinants of health.
UM Solutions for Every Line of Business
Aerial UM Connector is the latest addition to Aerial™, Medecision’s HITRUST CSF® certified, cloud-based platform and suite of applications for population health management. Other utilization management options available with the platform include Aerial Care Management®, a configurable workflow solution that automates care management, disease management, and utilization management. Particularly beneficial for commercial plans with large physician groups, Aerial iExchange® drives down wait times and reduces calls regarding authorizations and referrals. To meet the diverse utilization management needs for every line of business, Medecision will continue to offer each of these solutions.
“The complexity of the regulatory environment and audit process continues to increase,” said Gage. “The Aerial suite of solutions delivers compliance efficiency, transparency, and control so you can fully and easily meet CMS data universe and other reporting requirements.”