Solutions|Medicaid|Medicaid Management Solutions

Accelerate claims processing. Increase accuracy. Control costs.

Best-in-class services — available as individual modules or a complete system — built on an intelligent, automated cloud platform that supports the entire claims payment life cycle

Fast and accurate solution for Medicaid claims and encounters processing

Claims and encounter management must be accurate, efficient and cost-effective. But the challenge of achieving this grows as states adapt to an increasing volume of Medicaid enrollees, as well as comply with ongoing federal policy changes.

Gainwell can help you prepare to meet the challenge. Our Claims, Encounters and Financials Service module accurately processes claims and encounters and enables rapid deployment of policy changes. It facilitates maximum security, integrity and output to diverse trading partners and providers while meeting federal requirements.

Decades of experience in the Medicaid industry makes us uniquely qualified as your partner in the delivery of quality healthcare while ensuring that your state meets CMS requirements within budget. Claims, Encounters and Financials Service is an essential component of our Medicaid Management Solutions. This wide-ranging set of cloud-based services for healthcare interoperability combines automation, standardization and process maturity to support all aspects of Medicaid management, claims and payments.

The configurable module contains the tools to manage all aspects of claims, encounters and financial transactions. Your state can efficiently adjudicate and accurately process and pay large volumes of claims and encounters in real time.

Claims, Encounters and Financials Service provides enterprise-wide COTS modularity to support state-specific Medicaid needs and other health and human services programs. The module includes a world-class rules engine to support configurable, scalable and interoperable business functions. The service supports fee-for-service and managed care models.

A structured approach to serve high-risk, high-cost patients

We take a data-driven approach to care management, accounting for population stratification and risk scores, so your organization can take a structured approach to assigning members to specific clinical health management. You can identify members with chronic conditions and avoid costly hospital admissions and care by coordinating timely and essential services for members.

Gainwell Care Management Service strikes the balance between improving quality and reducing total cost of care. It uses data derived by proven, industry-standard COTS products, such as the Johns Hopkins ACG System, and includes administrative and clinical information to achieve these ends — all without creating an additional resource burden on your organization. Because we recommend targeted as opposed to one-size-fits-all interventions, the cost of administration is reduced and the ability to realize a positive ROI is greatly enhanced.

Limiting this technique to services that the data reveals as high-cost and high-use not only reduces the administrative footprint and service cost, but also improves provider relations. Prior authorization, as an example, can be an administrative burden for stressed provider practices.

Care Management Service, part of our Medicaid Management Solutions, is an interoperable module characterized by automation, standardization and process maturity. It provides a seamless process to interface with states’ other systems, optimizes workflows and simplifies reporting.

Accelerate drug rebate recoveries and easily manage any rebate policies

The Medicaid Drug Rebate Program has been successful in significantly reducing federal and state spending on drugs. But there are opportunities for you to realize even greater value by maximizing drug rebate collections and minimizing dispute resolutions.

Through the Gainwell Drug Rebate Service, your organization can easily manage any combination of rebate policies, including various federal pharmacy and managed care programs, and federal and state supplemental programs. Enhanced business processes make it possible to modernize drug rebate invoicing and to quickly and accurately apply payments. The solution supports fee-for-service, managed care and supplemental rebates.

This cloud-based service is a key module of our Medicaid Management Solutions, a platform built on COTS software that supports interoperability in healthcare and combines automation, standardization and process maturity to support all aspects of Medicaid processing.

Content-rich dashboards to drive operational improvements and enhance outcomes

Medicaid agencies must be more proactive about leveraging data to drive operational improvements and enhance health program outcomes. With greater insight into data, you can improve policy decision-making and align better with federal reporting requirements.

Gainwell’s inSight Analytics Service helps your agency get more use out of information that reflects claims, encounters, capitation, eligibility and enrollment activity. This dynamic tool enables your data analysts and information workers to interact with content-rich dashboards and multiple visualizations to discover metrics about your Medicaid population, such as eligibility, enrollment and participation, contractual SLAs, finance management and program expenditures.

Through our highly secure cloud and analytics platform your team can gather information from a variety of data sources. The platform then combines your data with a range of pre-integrated assets — such as clinical data, T-MSIS and third-party data flows. Drilling into the data enables you to track how metrics trend over time so, for example, you can discover unusual trends for earlier intervention and mitigation.

Part of our Medicaid Management Solutions, inSight Analytics is one of a set of interoperable modules characterized by automation, standardization and process maturity. It provides a seamless process to interface with states’ other systems, optimizes workflows and simplifies reporting.

Comprehensive services for MCO administration

Medicaid administration complexities increase as states grow their managed care organization (MCO) networks to deliver care to enrollees. Your organization can be more proactive in everything from cost-effectively managing multiple MCOs to tracking clients as they transition across MCO plans and to improving capitation processes.

Gainwell’s Managed Care Service helps you tackle these and other major challenges. We are a leader in delivering technology to cover all aspects of Medicaid management, claims and payments processes. Our Managed Care Service is one of the modules that comprise our Medicaid Management Solutions, a set of interoperable modules characterized by automation, standardization and process maturity.

The service helps you relieve the escalating strain on MCO benefits coordination as they bring new populations, add new services and extend the geographic range of coverage. Our cloud-based platform and SaaS approach, combined with our overarching services based on COTS software, are designed to help your organization better manage the present and prepare for the future.

Flexible services for automated Medicaid prescription drug program administration

Medicaid agencies face challenges in efficiently managing their prescription drug programs. Streamlining administrative and financial functions such as prior authorization, point-of-service claims and encounter processing is critical to reducing the complexities of the drug supply and payment chain.

Gainwell’s Pharmacy Service delivers dynamic pharmacy benefits management. It is an essential component of our Medicaid Management Solutions, a wide-ranging set of modules that support interoperability in healthcare and combines automation, standardization and process maturity to support all aspects of Medicaid management, claims and payments.

The advanced Pharmacy Service processes enable you to accurately adjudicate your state’s pharmacy claims within sub-second time frames and configure any policy changes in real time. This accelerates implementations and lowers costs in comparison to software coding. Our robust testing capabilities assure that configuration changes are successful.

Our flexible solution is based on COTS software aligned with industry and regulatory standards. Pharmacy Service supports fee-for-service and managed care models.

Find patterns and abnormalities to identify potential fraud and abuse

With the shift in healthcare services to managed care, there is a fundamental need to have a Medicaid fraud and abuse service that enables your investigators and managers to see across the entire healthcare program chain. Identifying, preventing and prosecuting Medicaid fraud and abuse cases — from false claims filing to prescription drug forgery — is a daunting task.

Gainwell’s Program Integrity Service addresses requirements for the Medicaid Certification for Program Integrity, together with utilization review and the ability to manage cases. While traditional fraud and abuse solutions are limited and look only at fee-for-service data, our service has been built from the ground up to give states the ability to investigate the complete spectrum of healthcare management models, both fee-for-service and managed care.

Our Program Integrity Service gives your investigators and analysts the analytical capabilities they need to quickly identify potential fraud. It also provides dynamic resource utilization analysis and robust on-demand reporting capabilities, creating an event or case trigger for follow-on actions when bad practices or behaviors are identified. Part of the Medicaid Management Solution, this comprehensive modular service combines automation, standardization and COTS products to meet the key challenges of Medicaid.

Comprehensive service for seamless, automated Medicaid provider management

Medicaid programs need to efficiently fulfill provider enrollment and screening requirements necessary to meet CMS mandates and ensure program integrity.

Gainwell’s Provider Service makes it easier for providers to participate in your Medicaid program. It is an essential component of our Medicaid Management Solutions, a wide-ranging set of services for healthcare interoperability that combines automation, standardization and process maturity to support all aspects of Medicaid.

Advanced functionality in our Provider Service module helps you seamlessly handle provider enrollments and screening, accurately identify providers in health plan networks and efficiently manage associated provider data. The solution increases maturity, efficiency and accuracy in provider processing, and provides the modularity and technology you need to deliver high-quality and timely Medicaid services.

We offer a cloud-based platform and a SaaS approach to help you manage provider information — from initial enrollment through the final termination letter. Our flexible healthcare services solution is based on COTS software aligned with industry standards. Our Provider Service tools support providers’ participation in fee-for-service and in other programs, including enrollment with MCOs.

Full service for cost avoidance and recovery

To ensure you maximize taxpayer dollars, your state agency is focused on cost avoidance and cost recovery. You can manage the first by having an efficient way to keep track of what other insurance a Medicaid enrollee may have (Medicare, private, employee-sponsored or other) and by using that data to avoid paying claims when other coverage sources are available. You can manage cost recovery by using that data to efficiently recoup fees or overpayments from the appropriate third party.

Gainwell’s Third-Party Liability Service will help your organization improve its ability to avoid costs and to recover fees quickly if mistakes are made. Our Third-Party Liability Service is part of our Medicaid Management Solutions, which provides built-in automation and process maturity support for all aspects of Medicaid.

Based on COTS software aligned with industry and regulatory standards, our Third-Party Liability Service is a single source for managing other insurance as well as cases for recoupment from liable third parties.

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