Support for Utilization and Care Management Programs for Medicaid Managed Care Geographic Expansion

Client Description

The client is a leading New England health insurer with a national reputation for quality and care management. This managed care organization covers over one million members across three states and offer a variety of commercial products in addition to Medicare and Medicaid products.

Challenge

Looking for expansion opportunities to grow both membership and revenue, the client launched an initiative to expand the plan’s experience with Medicaid Managed Care into a new State. The challenges were many: to be able to segregate the systems so data could be reported as a separate product line and to fully comply with the expansion State’s utilization management, care management, benefits, and quality requirements.

Ninestone’s Approach

Ninestone’s engagement was to provide project management and integrated clinical management program implementation support.

Ninestone was engaged to manage the implementation of the utilization and care management programs. We were the vendor of choice due to our rigorous project management approach and experience with clinical programs in addition to a long-standing client relationship.

Ninestone provided support for all of the clinical and care management work threads, including project management of all deliverables and facilitating stakeholder discussions for all technical solutions. To address the integrated care management requirements, Ninestone resources drafted the medical and behavioral health policies and procedures, workflows and any additional medical necessity guidelines for behavioral health program benefits.

Technology

Although Ninestone was not directly responsible for the technical solutions for this program, there were several technologies involved in this complex implementation that we participated in from a Business perspective, including:

health plan administration systems,
internal and external reporting,
web portals,
clinical systems,
new state regulatory reporting requirements.

Results

Along with entry into a new market comes the requirement to coordinate the implementation timeline with the state-mandated approval process. Due to a delay in submitting the product plan and a slow approval process, creative problem solving was required to manage many iterative work streams to get the critical path items lined up. As a result, Ninestone was able to mesh the business planning and approval process so that the utilization and care management programs were fully supported at go live from a business and technology perspective.