VH Insights

Best care management software for Medicare plans
September 08, 2022

How Can HELIOS Improve Medicare Advantage Plan Member Experiences?

Medicare Advantage (MA) plans have fully embraced whole-person, integrated care and are designed to provide members with much more than traditional clinical healthcare. Many provide additional value-added benefits and services such as dental, vision and hearing coverage, wellness rewards, and transportation to medical appointments.

From traditional Medicare Advantage plans to Medicare Advantage plans with prescription drug coverage (MAPD), to those that are specifically set up for dual-eligible individuals or persons with specific healthcare and/or financial needs (i.e., Dual Special Needs Plans or Chronic Care Special Needs Plans). All Medicare Advantage plans seek to provide a comprehensive suite of healthcare services and benefits.

But today, patients also want personalized care, transparency from providers and payers, and for their health to be as predictive and easy to manage as their Amazon account.

So how does a Medicare Advantage plan account for individual healthcare needs, varying populations, and social determinants of health (SDOH), while providing simple, impactful member experiences?

The short answer: a SaaS solution that leverages data-driven integrations, operational automations, and artificial intelligence (AI) to provide an efficient, more effective Medicare care management program.

Data and AI Can Help Solve Medicare Advantage Plan Challenges

Over the last decade, Medicare Advantage plans have exploded in popularity. CMS now projects over half of Medicare enrollees will select an MA plan within the next couple of years. As the Medicare Advantage population continues to grow, it also becomes more complex. In order to provide personalized, optimized, and cost-effective whole-person care, plans need to be able to process a higher volume of health data. An AI-driven and data-powered healthcare management platform like HELIOS® is integral for Medicare Advantage plans to:
  • Automate workflows and processes for operational efficiency
  • Reduce administrative burden of care management (CM) and utilization management (UM) teams
  • Validate data integrity and increase quality of plan’s submissions
  • Ensure/Maintain compliance with CMS, NCQA, HEDIS, and other regulatory bodies to achieve higher Star Ratings, CQMs, and other quality scores
  • Provide personalized, whole-person care that effectively supports the uniquely diverse needs of plan members
  • Accurately identify member, special status, and payment discrepancies
  • Proactively complete screenings to identify issues in the early stages and possibly reduce ED visits and admissions/readmissions
  • Easily identify, prioritize and work to close HEDIS and other care gaps at the member and population levels and leverage claims data through integrations to find evidence of compliance (i.e., mammogram report with date of service) or exclusion (i.e., bilateral mastectomy with date of surgery)
  • Connect data and insights for CM and UM teams to make better decisions
  • Maximize financial return by streamlining operations and processes
  • Adapt for varying social determinants of health and health-related social needs
  • Leverage community resources and integrated digital tools, such as transportation services and telemedicine respectively

Medicare Advantage plans require a compliant value-based care platform that is highly configurable, easy to use, and adaptable to real-time regulatory requirements and patient and provider needs.

HELIOS® Can Help Provide Better Medicare Member Experiences

Providing exceptional Medicare member experiences comes down to three things: (1) delivering proactive, value-based care, (2) providing effective care coordination, and (3) generating high levels of member engagement.

Enabling Proactive, Value-based Care for Medicare Advantage Members

HELIOS® uses AI-powered automations and workflows to help improve productivity by up to 92 percent. Multi-source data aggregation and intelligent configurations, enable HELIOS to proactively identify care gaps, flag risks, auto-populate care tasks, identify when a referral or community resource may be needed, and more.

The platform operates like a living ecosystem that continually captures and analyzes patient data to provide care management teams with real-time, 360-degree patient views that help deliver the right care, to the right patient, at the right time.

Some examples of how HELIOS® can help improve Medicare Advantage member experiences include:

  • Provide real-time view of more than 28 input sources of patient data
  • Quickly identify care gaps
  • Prioritize tasks for care management teams to serve patients better, faster
  • Alert care teams when a member’s prescription is about to run out
  • Help members access primary care providers and specialists easier
  • Provide virtual care and communication options for members who lack transportation or are limited on time
  • Enable proactive outreach to help members maintain physical, mental and emotional well-being
  • Keep all members of the care team connected to prevent data silos and ensure a collaborative, integrated approach to care
  • Accommodate members’ busy lives via built-in digital assessments, screenings, and surveys
  • Identify high-risk members so care teams can check in and help implement preventative measures or refer at-risk members to the appropriate providers, services, and resources

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Member-Centric Care Coordination Across Diverse Care Settings

A key element of value-based care that’s essential for members with Medicare is care coordination-especially for those with chronic health conditions and co-morbidities like diabetes, cancer or heart disease. As members transition from provider to provider and between acute care settings, long-term care facilities, and other services and settings, HELIOS helps ensure that care teams are promptly notified and able to adapt care models in real time.

  • Supports integration with a full spectrum of clinical sources (HIE. HER/EMR, ADT feeds, medical claims, pharmacy claims, authorizations, remote patient devices, etc.)
  • Automated case assignment and tasking to help with initial outreach and first-level screening and assessment
  • Enables coordination of admissions, discharges, and transfers (ADT)
  • Prompt notification and next-step tasking to the care team from event-driven triggers and real-time ADT feeds
  • Develop a holistic care plan with individualized care goals tailored to meet the needs and situations of each member
  • Perform medication management including reconciliation and adherence assessment
  • Seamlessly communicate with multidisciplinary teams
  • Engage and educate members and caregivers
  • Ensure patients can access health care services and appointments by leveraging virtual options or community resources and supports

HELIOS® Increases Member Engagement Opportunities

One of the advantages of the HELIOS® platform for Medicare Advantage plans is that it identifies more member engagement opportunities and makes them possible from within the platform with integrated telemedicine and patient engagement tools.

Some patient engagement tools include HIPAA-compliant, secure patient messaging, file sharing and management, patient calendar, interaction-based tasks, assessments and screenings, patient interaction tracking, and two unique HELIOS®-special telehealth solutions.

  • HELIOSvisit® - a secure, integrated telehealth solution where care teams and members can connect via videoconferencing. Members don’t have to install anything either; just click a link received via email or text message.
  • HELIOStext® - an integrated, secure messaging portal that lets care teams send secure outbound messages to expedite communications and provide greater transparency

Configurations to Match Individual Medicare Advantage Plan Needs

HELIOS® is also unique from other Medicare-focused care management and utilization management solutions in two ways. Its high configurability and easy-to-use, simple design.

In fact, 90% of HELIOS can be configured for specific needs and care delivery goals. Regulatory compliance is already taken care of. HELIOS® HIPAA and HITECH compliant, NCQA Pre-validated for Population Health Management, and HITRUST CSF certified

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