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Risk: Compliance Begins at Enrollment

Risk stratification reduces risk and improves quality outcomes


Better Data, Faster.

Risk is the front end analytics that help establish a member demographic and health risk profile to ensure sales and enrollment compliance and improve risk-adjusted reimbursement. Information captured at the front end of the process is critical to maintain regulatory compliance, avoid fines and penalties, and determine a plan’s reimbursement, directly impacting risk-adjusted premiums.

MedHOK’s Risk modules streamline the member enrollment process and enforce CMS’ regulations regarding data capture, keeping health plans in compliance using sophisticated tracking capabilities. In April 2015, MedHOK acquired Continuum Performance Systems, Inc. (CPS), and integrated the MarketProminence™ software into the MedHOK platform. MarketProminence allows Medicare plans to automate tracking and management of all membership data throughout the relationship lifecycle, from prospecting and enrollment to billing, customer service and retention. MarketProminence also supports ongoing compliance for Medicare-Medicaid Plan (MMP), Medicaid, and commercial enrollment processing and member management.

MedHOK combines over 1,300 proprietary and third-party certified rules and algorithms to predict, identify and target all member health risks, gaps in care and co-morbid health conditions that form the basis for risk scores and risk-adjusted reimbursement, and triggers automated workflows within the member-centric record.

Scroll down or use the menu to view the modules in the Risk area of the MedHOK enterprise compliance software platform.

Sales and Marketing

Part of MarketProminence, the sales and marketing function of the MedHOK platform assists plans with tracking and monitoring marketing and sales activities to ensure compliance with CMS guidelines and measure campaign effectiveness. These activities might include:

  • Overseeing mail and phone campaigns
  • Quantifying lead generation and qualification efforts
  • Deploying ongoing re-marketing programs
  • Managing broker efforts and effectiveness
  • Tracking field lead assignment and disposition
  • Rapid data entry of enrollment applications
  • Real-time or frequent batch load of application information to core enrollment module
  • Validation steps and alerts to ensure capture of complete enrollment information
  • Web-based broker portal with validation

Enrollment and Operations

MedHOK streamlines the enrollment process into Medicare Advantage, Medicare Part D Prescription Drug Plans, and Prescription Drug Plans. The enrollment functionality enforces CMS’ regulations regarding data capture and keeps Medicare Advantage/Medicare Advantage-Prescription Drug organizations and Prescription Drug Plan Sponsors in compliance using sophisticated tracking and audit capabilities.

  • Capture, validate, and track all required CMS election data in a Web-based enrollment portal
  • Automate application verification process
  • Track multiple source submissions, including broker, portal, and manual processing
  • Generate Batch Eligibility Query (BEQ) Response File for submission and response processing
  • Manage CMS file accretion and TRR response
  • Generate CMS and Medicaid compliant correspondence and alerts to ensure fulfillment in compliant timeframes
  • Assign and track provider assignments and date spans of all critical CMS components

Financial Reconciliation

MedHOK helps Plans resolve the data variances identified between the Plan and CMS.

  • Supports reconciliation of recorded membership data in system with CMS Monthly Membership Report (MMR) file
  • Reconciles enrollment and risk-adjusted revenue
  • Provides detail component level breakout of expected CMS PMPM payment
  • Reconciles 837 and RAPS claims submissions and adjust expected receivables (ICD-9 and ICD-10 as well as blended EDI/RAPS factors)
  • Aligns work payment variances to line item based on specific data elements and payment amounts
  • Manages recurring open variances through completion with complete archival tracking

Member Services and Customer Relations

Also a part of the MarketProminence product, this MedHOK module tracks member engagement and correspondence. Member service staff can view and access 360Member comprehensive profiles, based on role-based access and permissions.

  • Create coordinate of Benefits (COB) non-validated survey
  • Generate COB file to contractor and process updates with validated data
  • Generate and capture working aged survey data and collect and manage replies
  • Provide tracking and program management for Welcome Calls
  • Assess, generate and track Member Retention programs
  • Track and quantify Health Risk Assessments
  • Manage complex standard and expedited Grievance and Appeals within required time limits
  • Maintain and manage programs for Out of Area and Snowbird members

Complaints Tracking (CTM)

MedHOK’s Complaints Tracking module (CTM) is used to process complaints about dissatisfaction with any aspect of the operations, activities, or behavior of a health plan or its providers. Customers use this solution to respond to complaints made directly to CMS by the members or representatives; provide resolution to CMS within specified timeframes; and communicate with internal and external business partners to ensure the complaint is investigated thoroughly.

  • Connects to HPMS (CMS government website)
  • Automated movement of case through auto assignment
  • Quality review of CTM through Letter Review workflow task
  • Documentation of outreach for complete case file
  • Sub-tasking process for Internal Business Partner review
  • Automated correspondence generated and sent to fulfillment vendor
  • Outbound IVR call
  • Correspondence monitoring, documentation, and manual fulfillment if necessary


Manage all grievances across the organization with this CMS-compliant structured workflow module of MedHOK. The grievances module captures all key data elements needed for the consistent processing of cases. A dashboard allows for real-time monitoring of activity by management and promotes a proactive approach to administering caseload and meeting compliance deadlines. Tracking and trending allows for early recognition of opportunities for quality improvement.

  • Capture all key data elements needed for the processing of cases and routes cases to internal business partners at the plan to ensure rapid remediation
  • Take-in and process appeals of denied authorizations or claims payment in a timely and compliant fashion
  • Take-in and process grievances from members or member representatives
  • Communicate with external appeals entities and ensure any overturns are implemented
  • Respond to complaints made directly to CMS by the member that need resolution within specified timeframes

Provider Disputes

Provider Disputes is a workflow solution for processing and tracking disputes and denials from a provider with a concentrated focus on authorization and claim dispute/denial types. MedHOK offers a structured workflow based on individual user roles that ensures consistent case processing, complete effectuation, and automatic triggering of correspondence attached to the original case. The dashboard allows for real-time monitoring of activity by management and promotes a proactive approach to caseload and compliance deadlines.

  • Built-in ability to send sub-tasks to supporting departments
  • Auto-generate response letters
  • Smart-Logic embedded to ensure users track required fields
  • Fulfillment vendor integration to capture key compliance dates (Postmark, etc.)
  • Real-time monitoring of work in progress

Risk Adjustment/RADV

MedHOK’s Risk Adjustment/RADV module offers an end-to-end risk adjustment solution aimed at accurate assessment, improvement and reporting of diagnosis-based capitation factors that drive risk score calculation systems. This facilitates efficient and effective submission of risk adjustment data and drives maximum appropriate reimbursement from Medicare and other payment agencies. Plans can conduct mock audits or prepare for CMS RADV and other audits, in addition to proactively gathering medical chart review documentation to substantiate risk score submissions.

  • Creates CMS proprietary RAPS file for submission to CMS systems
  • Monitors required RAPS files to CMS’ FERAS and RAPS systems.
  • Comprehensive work flow ensures a swift remediation of any file and record errors, including updating key fields to ensure acceptance and HCC credit
  • Promotes quality outcomes by identifying high-risk members with chronic conditions to tie to Star and Care Gap closure
  • Analyzes incoming information for potential expiration (falloff of codes)
  • Estimates aggregate plan risk scores based on certified RAPS/MORs for future payment cycles as well as Falloffs and Opportunities
  • Estimates accrual revenue and future year revenue
  • Produces a random sample consistent with CMS methodology for mock audits
  • Intakes official CMS RADV audit universe for fulfillment
  • Adds critical eligibility, provider, and clinical information to each audit sample or CMS audit

Regulatory Tracking

MedHOK’s Regulatory Tracking Module consists of a Regulatory Memo Manager and a Special Investigation (SIU) Manager. The Regulatory Memo Manager is a simple and transparent solution to receive, manage, and track regulatory updates, including Health Plan Management System (HPMS) memos. The SIU Manager manages and tracks investigations of compliance incidents and potential healthcare fraud and abuse. It provides a simple way to manage workloads and timeliness via customized real-time dashboards, report issues and status to executive leadership, run reports for ad hoc and immediate reporting needs, and track Corrective Action Plans.

  • Distributes regulatory updates to accountable individuals within an organization
  • Allows for easy-to-understand action items for compliance, track and trend the types of actions required, and provides a simple way to report status to executive management
  • Creates an audit trail for each case and captures incidents, allegations, research, documentation, and tracking
  • Includes a dashboard and Business Intelligence reporting tool for ad-hoc and immediate reporting capabilities
  • Access to various functions and information is user-role configurable

Process Improvement (Root cause analysis)

MedHOK’s Process Improvement/Root Cause Analysis functionality runs across the platform but are rooted in the Risk area. MedHOK is able to trace the origins of a problem so that corrective measures can be put in place to ensure future success and alleviate identified problems.

  • Systematic workflow approach for identifying and reviewing Opportunity and Preventable issues for remediation
  • Standardized categorization of true root cause is captured for effective reporting
  • Comprehensive data capture allows for detailed reporting, including declaring if the identified problem presents an opportunity for process improvement or if the problem was preventable; root cause and source; and case workers’ detailed notes
  • Internal SLAs at various stages, with alerts and dashboard, to ensure timely investigation and resolution
  • Attachments can be uploaded as part of each case to track original issue, departmental remediation activities, resolution documents (e.g., test claims), and tracking of remediation activities (Adjust/reprocess/redistribute all impacted documentation/claims/checks, etc.)

Audit all actions taken as part of the RCA to ensure all providers and outbound items were accurately and sufficiently addressed and completed.

How can MedHOK Help You?

Would you like to know more about how MedHOK’s enterprise software platform can help you stay compliant and manage Risk, Care, and Quality across your organization? Complete the form and a member of our team will reach out to you shortly.

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