MedHOK’s Care Management modules assist in the identification of specific health risks and problems, and the implementation and documentation of appropriate interventions and goals. The Care modules focus on care coordination for improved clinical outcomes, complex case management, and patient-centric population health. The MedHOK platform triggers automated workflows based on identified gaps in care, quality, and/or compliance within the member-centric record, allowing for proper management of intervention.
The Care Management modules identify and target high-risk members, stratifying for varying care interventions and potential medication adherence risks. Structured workflows consistently monitor and intervene on care gaps to accelerate interventions. The member’s medical, pharmacy, lab, and other data are easily monitored from 360Member for a complete 360° view. These modules deliver consistent application of rules, requirements, and medical necessity standards, with clinical and quality mandates aimed at ensuring member outcomes actually improved.
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Predictive Modeling & Risk Stratification
The MedHOK Predictive Modeling and Risk Stratification module includes over 600 out-of-the-box algorithms to identify and stratify members. The solution allows business users to self-configure various algorithms combining Johns Hopkins risk stratification tool (ACG), HEDIS care gaps (if purchased), and claim and other data resident in the MedHOK system. Included in the solution is the ACG predictive modeling tool, which has financial, risk, utilization, and care gap algorithm components. Identified/stratified members can be triggered for interventions to the Utilization, Pharmacy, Medication Therapy Management, or Care Management modules. The software automatically routes members to a care management queue based on identified risk. This activity supports opening of active case and disease management cases for moderate to high risk members and fully automated health education and other preventive outreach for low risk members.
MedHOK’s predictive modeling, identification, and stratification solution provides hundreds of financial and utilization statistics as well as predicted values from which to stratify for case and disease management and care gaps. Based on the model output, MedHOK’s system also assigns risk scores and creates a comprehensive care profile for each member, providing a detailed assessment of the member’s morbidity, expected annual costs in different medical service areas, and potential for hospital readmission and other high-cost events. Each time additional encounter data is loaded, the predictive model is refreshed, and the new and underlying data is re-analyzed.
Case and Disease Management
The MedHOK Case Management solution includes numerous disease and case management out-of-the box assessments with problems, goals, interventions, and care plans auto-generated based on assessment answers. It includes comprehensive workflow with unlimited queues and project management to assign tasks to fulfill and monitor care planning.
Medication Therapy Management
Medication Therapy Management (MTM) and Drug Utilization Review (DUR) software offers a structured workflow solution for the processing and tracking of medication reviews, interventions and therapy changes performed on eligible beneficiaries of the MTM program. The software identifies beneficiaries at least quarterly for program enrollment based on established MTM program parameters submitted to CMS by Part D plans. The system measures and reports on the number of comprehensive medication reviews, number of targeted medication reviews, number of prescriber interventions and changes in therapy directly resulting from performed interventions.
Drug Utilization Review
MedHOK utilizes Medispan to identify additional interventions that may come up during medication reviews. MedHOK’s software identifies beneficiaries at least quarterly for program enrollment based on established MTM program parameters submitted to CMS by Part D plans. The system measures and reports on the number of comprehensive medication reviews, number of targeted medication reviews, number of prescriber interventions and changes in therapy directly resulting from performed interventions.
MedHOK’s Utilization Management module comes out of the box with Medicare fully compliant fields and drop downs to ensure CMS compliance. The out-of-the-box functionality is easily configured for other lines of business. The module includes multiple intake channels, auto-population of eligibility data, and structured workflows, tasks and work queues triggered by business rules to ensure consistent applications of rules, requirements and medical necessity standards. MedHOK can support business clinical criteria and is fully integrated with both MCG and InterQual clinical criteria. Includes a Business Intelligence reporting tool for ad hoc and immediate reporting capability along with canned reports and scorecard.
Customers use the Utilization Management module to conduct reviews from members or providers resulting from a medical request that was denied; conduct outreach, send correspondence, and effectuate approvals in claims systems; mnage medical documentation or plan review; and document completion of case to ensure all correspondence and closure steps followed or manual intervention occurred.
Pharmacy Prior Authorization
Pharmacy Prior Authorization is a fully CMS compliant workflow solution for managing prescription prior authorization for Medicare, Medicaid, and commercial risk-bearing entities. The module includes multiple intake channels and includes electronic prior authorization, auto-population of eligibility data, capture of all key data elements needed for processing the case and structured workflow with individual user roles and responsibilities.
- Supports prior authorization, step therapy, quality limits and exceptions.
- Drug by drug decision trees to ensure consistency in the drug decision-making process and immediate implementation of protocol changes with minimal associate learning curve. Correspondence is triggered automatically and attached to the original case.
- A dashboard allows for real-time monitoring of activity by management (internal or external) and promotes a proactive approach to administering caseload and meeting compliance deadlines.
- Automation of Prior Authorization allows for real-time auto-population of prior authorizations into the PBM claims adjudication system. This ensures members are able to receive their prescriptions in a timely manner.
- Alerts are configured to send proactive alerts to key business users to notify them of any possible issues. Alerts can be sent via email and are highlighted in the queue through case color changes (red and yellow). Alerts can be set to monitor queue case threshold volumes as well as compliance case or task due dates.
Medical Appeals is a workflow solution for CMS compliant processing and tracking medical appeals received from a member and/or provider. The system offers a structured workflow based on individual user roles with responsibilities/functions that define which task can be completed by the specific user. The system-defined workflow ensures that cases are processed consistently and timely. Also, the appropriate correspondence is triggered automatically and attached to the original case. The dashboard allows for real-time monitoring of workload by management, promoting a proactive approach to both workforce management and adherence to regulatory requirements.
Pharmacy Appeals is a CMS and Medicaid compliant workflow solution for processing and tracking redeterminations/pharmacy appeals for Medicare, Medicaid and commercial lines of business. The system offers a structured workflow system, ensures that cases are processed consistently and correspondence is triggered automatically and attached to the original case. Dashboard and proactive alerts allows for real-time monitoring of activity by management and promotes a proactive approach to case load and compliance deadlines. The real-time dashboards can be shared with your clients to promote transparency. Electronic Prior Authorization streamlines the process and reduces operational costs.
Health plans and Pharmacy Benefit Managers (PBMs) manage their formulary through the use of utilization edits that require authorization by the plan in order for the member to receive the prescribed drug. These Pharmacy Prior Authorization and Appeal requests are conducted and reviewed in the Pharmacy Authorization and Appeals system.
Users are able to manage formulary adherence by reviewing drug requests that require an authorization in order to be filled by the member; Conduct appeals from members or providers resulting from a drug request that was denied; Reimburse members for drugs filled out of network as allowed under the plan benefit; and conduct outreach, send correspondence, and effectuate approvals in claims systems
Specialty Pharmacy Management
MedHOK’s Specialty Pharmacy solution provides end-to-end oversight of the entire specialty drug order process and gives specialty pharmacies, plans, and providers the ability to operate patient-specific clinical programs that center on medication management to improve patient drug adherence and clinical outcomes.
Specialty pharmacies use the solution to process specialty orders by integrating with the PBM system for claims processing, and comprehensively manage a patient program, including onboarding of the customer for a new specialty medication, fulfilling the order, and ongoing care management and assessment. The solution holistically approaches specialty pharmacy management by conducting all order management, benefit management, fulfillment, and care management in one system, thereby reducing costs and improving member satisfaction
MedHOK’s Specialty Pharmacy solution gives Specialty Pharmacies the ability to operate patient-specific clinical programs that center on medication management to improve patient drug adherence and clinical outcomes. The solution utilizes an intelligent workflow system that optimizes the resources used to manage and perform drug, disease management and manufacturer programs for patients. The business configurable software solution allows for the creation, processing and tracking of patient/drug assessment programs to be performed in a structured workflow that automates the calendaring of assessments and the triggering of evaluations and interventions based on individual needs and program parameters. Reporting functions are available for all data collected in the system via standard “canned” reports and business intelligence (BI) tool.
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