Optum is teaming with Medecision and TriZetto to launch a first-to-market services-based offering for states' Medicaid Management Information Systems (MMIS), the critical IT foundation of the public health program for low-income people.
The new Optum Medicaid Management Services (OMMS) solution is a Software-as-a-Service (SaaS) and Business Process-as-a-Service (BPaaS) model that will enable Medicaid agencies to purchase only the IT, administrative and clinical services they need to effectively manage their programs – rather than buying costly and inflexible systems that often take several years and tens of millions of dollars to install and operationalize, and sometimes result in cost-overruns or outright failures.
"The Optum solution is analogous to states purchasing the electricity they need rather than building the entire power plant," said Steve Larsen, executive vice president, Optum Government Solutions. "Our state Medicaid clients have told us that traditional MMIS program administration approaches – now more than three decades old – needed upgrading to reflect the fast-paced environment and their broadened responsibilities under the Affordable Care Act; they welcome this modern, modular, services-based alternative."
A recent rule change by the Centers for Medicare & Medicaid Services (CMS) provides enhanced federal funding for Medicaid eligibility and enrollment systems, as well as MMIS claims systems, if they help automate application and renewal tasks, process claims more efficiently, and retire outdated legacy systems in favor of more flexible, modular, "efficient and consumer-friendly" solutions. The Optum services-based solution and the CMS rule-change now enable state Medicaid agencies to avoid the unwieldy IT implementation processes that accompany massive end-to-end MMIS system installations, and concentrate on their primary mission of improving the health outcomes of their beneficiaries – a goal that is becoming increasingly critical as Medicaid programs expand coverage in many states.
States that purchase services instead of setting systems requirements can benefit in numerous ways, including a shortened IT implementation period with less cost and reduced risk; more choices from proven commercial solutions that already work in the marketplace; improved administrative operations; and access to new technologies and cloud-based approaches that help agencies operate more flexibly.
Optum estimates that its SaaS approach could cut by as much as half the timeframe for new MMIS implementations, thereby significantly reducing the time and cost of implementation, and containing operational costs in both the short and long term.
Optum currently provides clinical, analytical, consulting, data, and technology solutions to 37 state Medicaid agencies and the District of Columbia. It will incorporate into its new solution Medecision's extensive population health management expertise, anchored by its flagship Aerial™ solution that supports best performance in meeting quality measures, integration of behavioral health with traditional health care management, and management of community-based services; and TriZetto's broad Medicaid claims and administrative platform, Facets™, which manages claims for nearly 30 percent of the Medicaid members who are covered by managed care organizations (MCOs).
"Medecision's people and technology help power the care that millions of American beneficiaries receive under Medicaid plans throughout the United States," said Deborah M. Gage, president and CEO, Medecision. "We focus on delivering compliant, community care-based applications that integrate behavioral and medical care decision support so that Medicaid beneficiaries receive optimal benefits. Through OMMS, we are proud to be part of delivering affordable, effective solutions that contribute to a healthier population."
"The expansion of managed Medicaid will be significant in the coming years, as the government continues to be the largest source of newly insured lives in the marketplace," said Krish Venkat, president, Healthcare and Life Sciences of Cognizant, parent company of TriZetto. "Platform-based solutions with flexible, as-a-service delivery models will be vital for health care organizations to address the demands of this growing market. We are pleased to team with Optum to bring the powerful and flexible capabilities of the Facets platform to the Optum Medicaid Management Services solution."
Traditionally, MMIS systems – which process Medicaid fee-for-service claims and managed care encounters, and provide reporting on the program – are formally certified by CMS. Such certification enables states to access enhanced matching federal funds at the rate of 90 percent for design, development and implementation, and 75 percent for operational expenses.
With Optum's new solution, states will structure their request for federal matching funds in the form of business services rather than system requirements. CMS auditors would certify that all services requested by the state and approved by CMS have been made available, and then make federal matching funds available to the state.
The Optum solution provides states the following:
- Business services, such as Medicaid fee-for-service claims processing, care provider enrollment, call center activities and operations reporting.
- Analytics and data warehousing services that can use data to help states identify needs across their population, focus resources accordingly to improve outcomes, and measure the performance of care providers, health plans and new state-managed programs to improve care.
- Health services such as wellness and care management programs to improve the health of Medicaid fee-for-service recipients.
In conjunction with the launch of its new solution, Optum has received certification from CMS as a "Quality Improvement Organization (QIO)-like" entity, a designation that enables it to perform quality improvement initiatives, and review cases and analyze patterns of care related to quality measures and medical necessity. The QIO-like designation allows states to receive 75 percent federal matching funds when Optum performs these services.
Optum is a leading information and technology-enabled health services business dedicated to helping make the health system work better for everyone. With more than 100,000 people worldwide, Optum delivers intelligent, integrated solutions that help to modernize the health system and improve overall population health. Optum is part of UnitedHealth Group (NYSE:UNH).
Leading Medicaid MCOs and Medicare Advantage plans depend on Medecision's team of experienced professionals and modular suite of Aerial™ integrated medical management, data aggregation and analytics, member engagement and Medicaid and Medicare-specific compliance solutions to power their population health management strategies and confidently grow their businesses. Medecision focuses on delivering compliant, community care-based applications that integrate behavioral and medical care decision support to help millions of American Medicaid and Medicare Advantage beneficiaries receive optimal benefits, while helping to control the cost of care with better utilization management and clinical best practices. www.medecision.com
About TriZetto, a Cognizant Company
TriZetto, a Cognizant (NASDAQ: CTSH) company and business unit within Cognizant's Healthcare and Life Sciences practice, provides world-class information technology and service solutions that help payers and providers work more efficiently and collaborate to deliver better health. Working with more than 350 health plans, TriZetto's technology solutions touch over half of the U.S.'s insured population and reach more than 260,000 care providers.
TriZetto's world-class technology products, in combination with Cognizant's consulting, IT, and business process services, dramatically simplifies the deployment and adoption of technology and improves operations. For more information, visit http://www.trizetto.com
TriZetto and the TriZetto triangle logo are registered trademarks and Facets is a trademark of the TriZetto Corporation.