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 solution will enable states to purchase only the information technology and clinical services they need, and avoid costly, time-consuming inflexible systems.
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.
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).
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.
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.