Healthcare Risk Management

We provide Specific Services that Aims to manage Medicare Members and Physicians for HMOs, MSOs and IPAs. Additionally, we can contract new physicians in such areas that our customers request.
We work with your marketing department for Membership growth and retention strategies.
hospital marketing dept

We encourage doctors to work with your marketing department for welcome letters from PCP (including PCP logos and/or photos) to potential current and new members.

We will collaborate with your marketing department for events such as community churches , Open House Mailings , Call center campaigns to newly enrolled, dis-enrolled or non-compliant members.

We oversee medical records review to maximize MRA or medicare risk adjustment. We review personally with the physicians on monthly medical management reports , such as;

  • HEDIS and Encounter audits/reconciliation
  • Claims reconciliation
  • Claims reconciliation
  • Review Encounters (capitated claims)
  • Incentive Program (HRAs)
  • Reconciliation of refund requests
  • Facilitate credentialing paperwork for new and existing providers
  • ER Utilization
  • HEDIS
  • Hospital Census
  • Care Management
  • Rx Utilization
  • Specialist Utilization
  • Coordinate with health plans on all PCP related initiatives
  • Support member outreach initiatives to bridge gaps in non-compliant measures
  • Develop decision support tools that aide in the PCPs ability to capture all open measures on a patient visit
  • Reconcile claims data to PCP submitted claims and/or medical records
  • Collaborate with other Provider Networks to close open measures
  • Monthly chart audits
  • Membership Trends by PCP group
  • Growth
  • Disenrollment patterns
  • Reconfirm PCP roster
  • Provide recommendations for changes in PCP status, e.g. open panels, close panels and terminations