The client is a leading Northeast managed care organization (MCO) with a Medicaid Managed Care program serving over 300,000 Medicaid members.
The organization was awarded one of the Commonwealth’s Accountable Care Organization and Managed Care Organization (ACO/MCO) Community Partner contracts required through MassHealth Reform, and needed to demonstrate within a short time-period its capability and readiness to proceed with development and implementation of the innovative three-way partnership with providers and Community based entities for care coordination. This MCO’s contract included multiple Statewide ACO partners and significant number of Long Term Services and Supports (LTSS) and Behavioral Health (BH) Community Partners (CPs). MassHealth’s requirements for demonstrated readiness documentation had to address and incorporate new contractual business and care management understandings. Existing policies, procedures and processes for providers, utilization and care management, and quality activities had to be reviewed and organized. Where gaps were identified, updated or new policies and processes had to be developed.
Ninestone brought deep capability for regulatory business analysis and program development to the Care Management Departments required documentation preparation and timely submission; developing the BH Department specific workplan, reviewing, identifying gaps and organizing for final submission, the required readiness documentation materials that included cross-departmental policies, procedures, and processes.
Readiness activities required development of a detailed workplan that included a Care Management Department responsibility to identify of the most efficient and effective method of exchanging CP eligible referral data and information with ACOs and CP. Further, the Care Management Department was tasked with the need to develop an analytic solution to gather each eligible member’s relevant claims and utilization information to accompany the CP assignments.
Ninestone maintained the required timeline, delivered required readiness documentation. The organization is currently sustaining support of the program with internal staff as the planned implementation date approaches.
- Business Analysis and Program Support for Joint ACO, MCO and CP Roles, Responsibilities and Processes Facilitation and Implementation
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- Performance Improvement
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- Compliance and Regulatory
- Program and Project Management
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