Monika Vashishtha (MBA, PMP, ITIL)’s Post

What is MMIS? MMIS is an integrated group of procedures and computer systems used by state Medicaid agencies. Its primary functions include: • Claims Processing: Handling medical claims for Medicaid services. • Provider Management: Enrolling, credentialing, and reimbursing Medicaid providers. • Member Management: Supporting eligibility, enrollment, and care coordination for Medicaid beneficiaries. • Data Reporting: Providing data for federal and state reporting, performance evaluation, and audits. • Program Integrity: Detecting and preventing fraud, waste, and abuse in Medicaid programs. Medicaid Management Information Systems (MMIS) via NewgenOne EDM + CCM Software Platform The Newgen Advantage Medicaid programs across the U.S. are increasingly prioritizing modularity, compliance, and member-centric services. Newgen Software’s Enterprise Content Management (ECM) and Customer Communication Management (CCM) modules, powered by the NewgenOne Platform, bring transformative capabilities to Medicaid Management Information Systems (MMIS). NewgenOne’s ECM and CCM modules seamlessly integrate with MMIS core systems to: • Simplify document handling across MMIS workflows. • Automate communication generation and delivery. • Ensure CMS compliance through built-in features and advanced security controls. Talk to us or ask for DEMO. Cheers 🍻 Manish Jaiswal 646.644.3049 Newgen Software

CMS recently finalized rules aiming to improve healthcare data exchange and streamline prior authorization processes. The rules apply to various payer types, including #Medicare Advantage, #Medicaid, and CHIP programs. Payers need to implement several new APIs to facilitate data sharing with patients, providers, and other payers. Key Requirements: - API Implementation: Payers must implement various APIs for data exchange, including: - Patient Access API: Allows patients to access their claims and clinical data through health apps. - Provider Access API: Allows providers to access patient claims and some clinical data. - Payer-to-Payer API: Facilitates data exchange with other payers for new enrollments and concurrent coverage. - Prior Authorization API: Enables electronic submission and decision-making for prior authorization requests. - Prior Authorization Deadlines: Respond to standard requests within 7 days and expedited requests within 72 hours. - Public Reporting: Share data on prior authorization approvals, denials, and appeals annually. Benefits for Payers: - Improved care coordination and management through better access to patient data. - Reduced administrative burden with streamlined data exchange and automated tasks. - Enhanced fraud detection and prevention with real-time data access and improved analysis. - Streamlined prior authorization processes with faster submissions and fewer denials. - Increased member satisfaction and retention through improved care and easier access to information. Challenges for Payers: - Technical challenges: Integration complexity, data standardization, security concerns, and limited resources. - Operational challenges: Workflow disruptions, data quality management, interoperability with non-compliant providers. - Financial challenges: Implementation and maintenance costs, potential revenue impacts. - Regulatory and legal challenges: Complex regulations, compliance requirements, and potential legal risks. - Additional challenges: Lack of industry-wide standards, limited provider readiness, and potential stakeholder resistance. Overall, the new CMS rules present both opportunities and challenges for payers. Implementing these requirements will require careful planning, investment, and collaboration with various stakeholders to ensure successful adoption and achieve the intended benefits. Learn more: https://hubs.ly/Q02lNxbp0

Real IT experts cannot complete a real project for a fake price you got from fake IT experts. Fake IT experts will promise things like a government medicare EHR system for $2,500,000 developed from scratch. Just the legal certification work on a medicare project is up to $20,000,000! The data modeling structure is $36,000,000 to over $50,000,000! The retail copyright sale price for ANY type of EHR starts at $4 BILLION; even for an old one. A new real-time EHR with integrated Sales, FHIR, Canonical data exchange, ERP, CRM, AI/BI, SCM, etc. starts at $30 BILLION. The real-world development cost of a new real-time secure and modern medicare compliant EHR is $900,000,000 over 36+ months. It is the size of two ERP projects due to complex eligibility requirements and constant additions to the law which has restrictions by age, location, payment type limits, coverage gap limits, etc. Medicare laws change at least once per year, which causes cascading changes system-wide. However, the system must also operate in the previous mode with previous versions of the law for care rendered before new changes in the law took effect. The data model has to be extremely advanced to keep up with changes in the law by anticipating what can and will change and shifting the logic to changes in settings and data instead of multiple changes to the data model structure. Otherwise, the legal change updates alone could cost over $1 BILLION per year per EHR. If the EHR is not updated correctly, there will be millions to billions in fines, reduced medicare reimbursement, information blocking, etc. Also, medicare requires anti-fraud, which requires real-time data capable of multidimensional temporal atomic data model structures. There is no way a fake IT expert can do that. At best, they can make one big insecure, poorly performing table that is in the format of a fake webpage. Companies have paid over $1.5 BILLION in medicare fraud cases because they cut corners and cut costs in analysis and design for business requirements analytics and data modeling structure design which encodes law directly into the UML structure to enforce requirements collected during the analysis. https://lnkd.in/gzriRRJ3 https://lnkd.in/gxQjwPAQ

CMS recently finalized rules aiming to improve healthcare data exchange and streamline prior authorization processes. The rules apply to various payer types, including #Medicare Advantage, #Medicaid, and CHIP programs. Payers need to implement several new APIs to facilitate data sharing with patients, providers, and other payers. Key Requirements: - API Implementation: Payers must implement various APIs for data exchange, including: - Patient Access API: Allows patients to access their claims and clinical data through health apps. - Provider Access API: Allows providers to access patient claims and some clinical data. - Payer-to-Payer API: Facilitates data exchange with other payers for new enrollments and concurrent coverage. - Prior Authorization API: Enables electronic submission and decision-making for prior authorization requests. - Prior Authorization Deadlines: Respond to standard requests within 7 days and expedited requests within 72 hours. - Public Reporting: Share data on prior authorization approvals, denials, and appeals annually. Benefits for Payers: - Improved care coordination and management through better access to patient data. - Reduced administrative burden with streamlined data exchange and automated tasks. - Enhanced fraud detection and prevention with real-time data access and improved analysis. - Streamlined prior authorization processes with faster submissions and fewer denials. - Increased member satisfaction and retention through improved care and easier access to information. Challenges for Payers: - Technical challenges: Integration complexity, data standardization, security concerns, and limited resources. - Operational challenges: Workflow disruptions, data quality management, interoperability with non-compliant providers. - Financial challenges: Implementation and maintenance costs, potential revenue impacts. - Regulatory and legal challenges: Complex regulations, compliance requirements, and potential legal risks. - Additional challenges: Lack of industry-wide standards, limited provider readiness, and potential stakeholder resistance. Overall, the new CMS rules present both opportunities and challenges for payers. Implementing these requirements will require careful planning, investment, and collaboration with various stakeholders to ensure successful adoption and achieve the intended benefits. Learn more: https://hubs.ly/Q02lNxbn0

CMS recently finalized rules aiming to improve healthcare data exchange and streamline prior authorization processes. The rules apply to various payer types, including #Medicare Advantage, #Medicaid, and CHIP programs. Payers need to implement several new APIs to facilitate data sharing with patients, providers, and other payers. Key Requirements: - API Implementation: Payers must implement various APIs for data exchange, including: - Patient Access API: Allows patients to access their claims and clinical data through health apps. - Provider Access API: Allows providers to access patient claims and some clinical data. - Payer-to-Payer API: Facilitates data exchange with other payers for new enrollments and concurrent coverage. - Prior Authorization API: Enables electronic submission and decision-making for prior authorization requests. - Prior Authorization Deadlines: Respond to standard requests within 7 days and expedited requests within 72 hours. - Public Reporting: Share data on prior authorization approvals, denials, and appeals annually. Benefits for Payers: - Improved care coordination and management through better access to patient data. - Reduced administrative burden with streamlined data exchange and automated tasks. - Enhanced fraud detection and prevention with real-time data access and improved analysis. - Streamlined prior authorization processes with faster submissions and fewer denials. - Increased member satisfaction and retention through improved care and easier access to information. Challenges for Payers: - Technical challenges: Integration complexity, data standardization, security concerns, and limited resources. - Operational challenges: Workflow disruptions, data quality management, interoperability with non-compliant providers. - Financial challenges: Implementation and maintenance costs, potential revenue impacts. - Regulatory and legal challenges: Complex regulations, compliance requirements, and potential legal risks. - Additional challenges: Lack of industry-wide standards, limited provider readiness, and potential stakeholder resistance. Overall, the new CMS rules present both opportunities and challenges for payers. Implementing these requirements will require careful planning, investment, and collaboration with various stakeholders to ensure successful adoption and achieve the intended benefits. Learn more: https://hubs.ly/Q02lNlbq0

An excellent primer on how the right evidence in the right, interactive context can help healthcare stakeholders make the best decisions

🔑 Unlocking Success with Credentialing & Provider Enrollment In the world of healthcare, credentialing and provider enrollment are vital steps that directly impact your practice’s ability to see patients and get reimbursed. Yet, they’re often time-consuming and complex, creating unnecessary delays and revenue interruptions. With 7+ years of experience in medical billing, I specialize in streamlining these processes to ensure providers are enrolled with payers efficiently, so your practice can focus on delivering quality care. What is Credentialing & Provider Enrollment? Credentialing is the process of verifying a provider’s qualifications (licenses, certifications, and experience) to ensure they meet payer and regulatory standards. Provider enrollment involves registering providers with insurance companies so they can bill and receive payments for their services. Why Are These Steps Critical? ✅ Timely Reimbursements – No enrollment means no payments. ✅ Compliance Assurance – Proper credentialing prevents compliance issues. ✅ Enhanced Patient Access – Allows patients to use their insurance, increasing patient satisfaction. How I Can Help Your Practice: 1️⃣ End-to-End Credentialing Comprehensive verification of provider credentials, ensuring accuracy and compliance with payer requirements. 2️⃣ Efficient Enrollment Processes Completing and submitting provider applications to insurers, minimizing delays and errors. 3️⃣ Payer Follow-Ups Regularly tracking application status and resolving any issues to speed up approval times. 4️⃣ Contract Negotiations Assisting with payer agreements to secure optimal reimbursement rates for your practice. 5️⃣ Maintenance of Credentials Monitoring license renewals and re-credentialing deadlines to avoid disruptions. Why Choose Me? Specialized Expertise: Extensive experience with Medicare, Medicaid, and private payers across multiple specialties. Multi-Platform Knowledge: Proficient in handling credentialing via various platforms like CAQH, PECOS, and payer-specific portals. Custom Solutions: Tailored strategies to meet the unique needs of your practice. 📩 Let’s Work Together! If credentialing and enrollment challenges are holding your practice back, let’s connect. I’ll take care of the paperwork so you can focus on providing exceptional care to your patients. #MedicalBilling #Credentialing #ProviderEnrollment #RevenueCycleManagement #HealthcareSolutions #PracticeGrowth

Credentialing Is Impacting Physician Profitability By As Much As 30%! Did you know that credentialing significantly affects your bottom line and staying in-network is vital to the success of your practice? We routinely find that credentialing is a top 8 cause of denials. 1st Credentialing is a highly focused Credentialing Group that is specifically designed to support the needs of hospitals, physician groups, urgent care centers, community health centers, behavioral health facilities, telehealth providers, vision providers, and more. With our help, healthcare organizations reduce enrollment expenses by up to 33% and credential providers 2-3 weeks faster resulting in higher revenues. Credentialing is essential for effective medical billing and revenue cycle management because it ensures that: • Providers are qualified and recognized by payers, which facilitates accurate billing and reimbursement. • Compliance and fraud risks are minimized. • Revenue cycle processes are streamlined, leading to improved financial performance. • Positive provider-payer relationships are maintained. • Patient satisfaction is enhanced through reliable billing practices and access to in-network care. Proper credentialing supports the smooth functioning of the entire revenue cycle, ultimately leading to better financial health for healthcare organizations and improved care experiences for patients. Tips to Stay In-Network:   1. Update CAQH profiles timely 2. Know your re-credentialing dates for each insurance and provider 3. Make changes to your insurance contract timely such as location and ownership updates 4. Respond quickly to any correspondence related to credentialing. 5. Use credentialing software, like www.1stCred.com to stay on top of the process.

Key Considerations for IOP Billing Documentation: Accurate and detailed documentation is vital for proper billing. Ensure that all services provided, including therapy sessions, group sessions, medication management, and any additional services, are documented thoroughly. Medical Necessity: To obtain reimbursement, it is crucial to demonstrate the medical necessity of the services provided. This can be achieved by documenting the patient's diagnosis, treatment plan, and progress notes, indicating why IOP services are essential for their well-being. Compliance with Guidelines: Stay updated with the latest billing guidelines and regulations issued by insurance companies, Medicare, and Medicaid. Adhering to these guidelines helps ensure proper reimbursement and reduces the risk of audits and compliance issues. Verification of Benefits: Before providing services, verify the patient's insurance coverage and benefits. This allows the facility to understand any limitations or restrictions that may affect billing and reimbursement. Modifiers: Utilize appropriate modifiers when necessary to indicate specific circumstances or services provided. Common modifiers include GT (via interactive audio and video telecommunications systems) and 95 (synchronous telemedicine service).

🌟 Transforming Healthcare, One Bill at a Time 🌟 At RT Med Solutions, we understand that healthcare providers are dedicated to delivering the best care possible. However, navigating the complexities of medical billing can often be a daunting task. That's where we come in. Our mission is to support healthcare providers by streamlining their billing processes, ensuring compliance, and maximizing revenue. 🔹 Why Medical Billing Matters: Medical billing is not just about processing claims; it's about ensuring that healthcare providers receive fair compensation for their services. Proper billing can make the difference between a thriving practice and one that struggles to stay afloat. By partnering with RT Med Solutions, providers can focus on what truly matters—caring for their patients—while we handle the intricate billing processes. 🔹 Our Commitment to Excellence: At RT Med Solutions, we take pride in offering tailored solutions that meet the unique needs of each practice. Whether it's accurate coding, comprehensive AR management, or efficient denial resolution, our team of experts is dedicated to delivering excellence at every step. 🔹 Specialized Services for All Providers: From behavioral health and urology to general practice and specialty care, our services are designed to cater to diverse healthcare fields. We stay updated with the latest coding guidelines and payer requirements to ensure maximum reimbursements and minimal claim rejections. 🔹 Credentialing Services: We know that credentialing can be a complex and time-consuming process. That’s why we offer free credentialing for one insurance of your choice, allowing you to experience our top-notch services. Our credentialing experts ensure that you meet all regulatory requirements and avoid costly disruptions. 🔹 A Partner You Can Trust: Choosing RT Med Solutions means choosing a partner committed to your success. Our client-focused approach ensures personalized support, regular updates, and a seamless experience. Let us handle the complexities of billing and credentialing, so you can focus on what you do best—providing exceptional care. 💼 Join Us in Making Healthcare Better: Together, we can build a more efficient and effective healthcare system. Partner with RT Med Solutions and experience the difference that expert billing and credentialing services can make for your practice.