Challenge

To qualify for Cal MediConnect, an in-depth analysis of HPSM’s operational capabilities was conducted by CMS and the State of California. In order to comply with the new and more rigorous requirements of the Cal MediConnect program, HPSM required some modifications to the core application to integrate this business with current lines.

The Solution

HPSM is an existing client of RAM Technologies. The organization selected RAM after an exhaustive and diligent selection process. HPSM appreciated RAM’s attention to all levels of the organization, as well as RAM’s specialized focus and in-depth knowledge of Medicare, Medicaid and dual-eligible programs.

“When we went to upgrade our previous claims system, we initially thought that we’d go with the incumbent vendor,” said Eben Yong, director of MIS for HPSM. “However, RAM showed us a lot of interest, had great functionality, and RAM’s CEO actually came out to visit us. They were even willing to develop new functionality that we wanted. That level of service made us choose RAM.”

Working within a short turnaround time, both teams worked closely together to outline the specific business requirements of Cal MediConnect, develop functional specifications and modify the software to address the readiness review demands of the state and federal governments. Once these areas were addressed, the updates were implemented and HPSM staff received training on the use of the software’s updated functionality.

Results

As a result of this joint effort, and the enhancements to the HEALTHsuite Mercato solution, HPSM passed its claims readiness review and was subsequently approved for participation in Cal MediConnect. Through Cal MediConnect, HPSM has expanded its market share and increased revenues.

“Working with RAM on the upgrades was a very easy process,” Yong said. “It took us about three months to design, implement and test the upgrades.”

Using HEALTHsuite Mercato to manage the Cal MediConnect dual-eligible program, HPSM  converted information on 7,500 transitioning members to the RAM solution; HPSM’s Cal MediConnect Program now has nearly 11,000 members.

Since using HEALTHsuite Mercato, HPSM has increased its auto-adjudication rate to 94 percent. “Using HEALTHsuite, we’ve been able to keep our auto-adjudication rate in the low to mid 90s even with all of the changing healthcare regulations that have been taking place,” Yong said.

The symbiotic working relationship between RAM and HPSM enabled HPSM to meet the conditions for passing the readiness review within a very tight timeframe. “Our understanding of HEALTHsuite, combined with its functionality, make the solution a perfect match for us,” Yong said.