Medical Research Administration for Medicare
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| The Task: |
| To develop a system wherein the details of the member’s healthcare risk assessment is done and reviewed in a structured and user friendly manner. The task was to create and cover all the various data that were possible under each field like demographic details, risk conditions as well as stating levels for each of the conditions and other related healthcare review details. A provision for updating or altering data within fields was also a requirement to keep in pace with the latest alerts. |
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| The Challenges |
| The client used to keep a database of its patient’s risk assessment manually through files. The challenge here was to be able to provide an automated solution wherein the access for bulky information is easier and well segregated respectively. |
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| The Solution |
| Binary Spectrum created an online reviewing system for accessing the various risks involved in patient’s healthcare. Through this solution it has well segregated the patient details, the reviewing system, the reporting and resource management processes. The HMO aims to use this system as a way of keeping track about the patient’s healthcare and the risk levels he / she faces in order to avoid him / her to be negligent in their healthcare and claim for the services that they seek from the provider. |
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| There are 5 main modules under MRA. They are Chart Review, Referrals, Disease Management, Case Management and MRA Scores. Medicare pays the Insurance companies based on the MRA Score. MRA score typically tells the Medicare System about the diagnosis details of patients. |
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A higher RISK score would indicate that the condition of the patient’s health is worse. |
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The core function of the MRA team is to ensure that all member’s/patient’s health condition is normal and try to maintain a lower RISK score. |
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| The functionalities of this system include: |
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MRA details - It acts as a dashboard with the overview of the various tests and medication of each patient. |
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Chart Review - The MRA review system will support a comprehensive platform for the MRA team to review the charts of members enrolled through each of the listed insurance companies. Details of patient condition, the diseases he / she is suffering, physician attestation report or unresolved reports and latest updates of diagnosis of each patient can be viewed and attested accordingly. |
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Health Maintenance – This contains details of different tests conducted, screening details like colorectal screening, heart attack event, EKG results, etc with the date on which they were performed. |
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Care Management – Risk conditions of the patient is reviewed here. The various risk conditions like CAD, COPD, CHF, CKD, Diabetes Mellitus, Depression and Stroke are classified into different levels on the basis of degree of risk involved. |
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Admin Reports – This provides the details of the charts reviewed by the user (MRA Analyst).The reports are auto scheduled to super admin on daily basis. |
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Role management-This provides access privileges to the modules of the application depending on roles. |
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| The Result |
| The client is productively utilizing this application and finds it more valuable and feasible to handle large amount of patient’s data. The system integrates the Clinical Information from EMR, Patient Demographics, Patients Visits and Billing Information from PM and Insurance Reports from Insurance Companies so that the MRA team is able to review these charts and RISK scores with ease. |
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| look at other HMO case studies |
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CRM: |
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Managing campaigns, events, leads and enrolling Medicare members |
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Managing website portal with regulatory content for compliance |
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Standard reports for CMS and Sponsors |
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EDI: Business to business platform for bulk transactions |
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Online Analytical Processing |
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Health Reimbursement Arrangements |
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