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Community-based Health Plan Improves Submission Rates And Recaptures Lost Revenue

by Babel Health

July 18, 2018

Commonwealth Care Alliance® (CCA) is a not-for-profit, community-based healthcare organization based in Massachusetts. CCA is dedicated to improving care for a population of more than 27,000 individuals who are dually eligible for Medicaid and Medicare and often have complex medical, behavioral health and social needs, including many persons with disabilities.

New encounter data management leadership determined that the
organization faced three pressing issues that needed to be resolved quickly:

  1. The legacy EDPS/RAPS submission solution did not allow any control
    over the submission process, which provides key data used to determine
    the Medicare payment rate for each member. Once CCA issued
    encounter data to the existing vendor, CCA lost control over the entire
    process, making the organization wholly reliant on the vendor’s
    schedules, submission cycles, and reporting capabilities.
  2. CCA had no ability to perform ad hoc or batch error correction
    without extensive technical eff orts to modify data transformations
    from the core adjudication system. Th is meant that CCA’s risk-based
    payment lagged in relation to the submission of corrected encounter
    data. Furthermore, the solution lacked integration with RAPS data,
    which meant gaps could not be identifi ed and corrected in a timely
  3. CCA needed an “off the shelf” solution that would minimize internal
    IT support requirements and allow the organization to refocus their
    technical assets towards strategic priorities.

View the full whitepaper below to see how CCA resolved these issues