2 min read

[PR] Pathway Health Selected as Training and Implementation Partner for Managed Care MASTER Application

By Prime Care Tech Marketing on Wed, Apr 18, 2018 @ 01:59 PM

LAKE ELMO, Minn., April 18, 2018Pathway Health has been selected by Prime Care Technologies and its affiliate Managed Care Group LLC as their implementation, training and ongoing support services partner for their new app, Managed Care MASTER. Through this partnership, Managed Care Group will leverage Pathway Health’s vast network of more than 150 clinicians and technology experts to provide comprehensive implementation and training support.

“We selected Pathway Health due to its deep knowledge of the post-acute care continuum and nationwide network of expert consultants,” said Jim Hoey, Prime Care Technologies CEO. “As momentum builds for our best practice case-management solution, this partnership will enable us to better support our customers as they work to simplify their managed care processes.”

Managed Care MASTER utilizes best practices from 18-year managed care expert Mix Solutions, Inc. The case management and reimbursement app synthesizes data from managed care contracts, EMR systems and case management reports. Through the use of the app, skilled nursing care providers are empowered to maximize managed care reimbursement.

“We look forward to supporting Managed Care Group’s innovative application,” said Pathway Health Chief Executive Officer Peter B. Schuna. “As providers continue to implement strategies to improve patient outcomes while lowering costs, leveraging state-of-the-art technology will play an important role in providing quality, patient-centered care.”

About Prime Care Technologies 
Since 2003, Prime Care Technologies has equipped long-term care providers with flexible hosting, managed services and cloud software that evolve based on industry demand. Based in Atlanta with 150 employees and 200+ healthcare/IT partnerships, its technology-driven solutions are installed in 6,500+ facilities. With deep multi-vendor interoperability expertise, including the integration of 70+ healthcare applications and 3,500+ EDI payers, Prime Care Technologies offers the leading data warehouse and claims clearinghouse in post-acute care. Its affiliate, Managed Care Group LLC, has partnered with leading post-acute care vendors and subject-matter experts to develop software that drives automation and efficiency to the relationships between providers and managed care organizations. Synthesizing data from managed care contracts, EMR systems and case management reports, Managed Care MASTER empowers skilled nursing facilities (SNFs) to maximize managed care reimbursement. Learn more at www.primecaretech.com.


About Pathway Health

Pathway Health is a professional management, consulting, interim management, talent search, interim management and education services organization, serving clients across the post-acute care continuum. Since 1997, Pathway Health has been keeping a pulse on industry clinical, regulatory, quality and reimbursement trends to keep clients on the path to success. With over 150 experienced professionals, we engage and employ leading clinical and operational experts to assist our clients in achieving the next level of performance. Learn more at www.pathwayhealth.com.



Prime Care Technologies




Topics: MCO contract MCO claims contract management Pathway health Managed Care MASTER Managed Care Group case management for managed care case management support Prime Care Technologies Training and implementation partner managed care software managed care app
3 min read

Simplifying the Managed Care Claims Process

By Prime Care Tech Marketing on Thu, Nov 19, 2015 @ 07:00 PM

ClaimsAn associate of mine at primeCLAIMS, recently related a turn of phrase that I agree can apply to working with managed care organizations (MCOs), “If you’ve seen one contract, you’ve seen one contract.”  Depending on the number of managed care organizations your company or facility works with, billing the right payer and submitting the correct claim with the correct information can be quite complicated. MCOs have parallel as well as divergent policies for correct claims submission. Knowing what those contractual requirements are and fulfilling those requirements is the key. So, how does a biller keep this as simple as possible?

What’s in each contract – knowing what is covered, not covered

The devil is in the details. And since each MCO contract may be different from the others, billers should understand what’s in each. The contracts may specify:

  • Levels of care by RUG scores or service levels, which specific diagnosis codes are allowed, how many days are considered co-pay days, which ancillaries are covered in the base rate and which may be billed separately or not at all, if a pre-authorization[1] and re-authorizations for a stay is needed, and so forth. Most will agree that no two MCOs are alike. Knowing what services and procedures are covered is essential to and getting paid at the proper pay rates without unnecessary delays.

Caution: Billers need to be mindful that facilities may admit a resident/patient who is to be covered by managed care, but with whom the provider does not yet have a contract. In that event, the provider may not receive full pay for services rendered since the MCO in question may consider the claim out-of-network.

What’s in each contract – knowing how to complete the claim form

Billers need to have a working knowledge of what each MCO expects to have included in the claim form as stipulated in each contract. We recommend that billers have access to the contracts and to know what each requires. Our Managed Care Master App can help. 

Keeping it all in one place – a ready reference

We advise all providers to compile all of their managed care contracts into one location, perhaps a tickler file, a file drawer with a folder for each contract, or a binder. In front of each contract, providers should place a completed summary form highlighting what each payer will pay for under what circumstances using which codes, paying how often. Each summary sheet highlights the essentials that must be included in each claim and should serve as a reference tool during the triple-check meeting. Or better, if you don't want to physically maintain contracts, check out our Managed Care MASTER app for housing your contracts online with easy-to-reference contract summaries.

Set up the system correctly the first time

Another best practice to help simplify the process is to set up each contract’s claims requirements within the billing software, such as rates, included and excluded diagnosis codes, etc. Word to the wise - Take the time now to set it up properly or deal with possible problems later[2].

Last Word

The managed care billing process can be easier to manage if providers will:

  • Use available technology, like Managed Care MASTER, or set up a reference binder for each contract and its summary. All billers need to become familiar with each contract.
  • Correctly set up the contract provisions within the billing software.
  • Refer to the contract summary sheets during the triple-check process.

One More Last Word

My primeCLAIMS colleague, Mike Giel, suggested we mention that in the contract negotiation period, providers need to discuss what provider enrollment procedures the MCO requires before claims can be submitted electronically. Think of it this way. The contract is the key to opening the claims flow door. The enrollment form opens the door. Completing, submitting, and receiving approval prior to submitting the first claim will ensure that the door is open and remains open so that claims can go and payments come in unhindered.  

It just makes good cents.

[1] Example: Pre-authorizations are usually required to pre-approve a specific length of stay. Providers may need to get authorization to extend the stays beyond the initial authorized period. If providers don’t secure a reauthorization, they will have to worry about who will pay for the rest of the stay. Knowing that in advance can eliminate frustrations for all involved: the resident, the resident family, and the provider.

[2] Note: Contracts have a life of their own and can change over time. When those changes occur, record them in the contact binder and billing software set up.

 Claims Process

Topics: claim form triple check MCOs MCO contract Managed Care Organizations MCO claims RUG scores levels of care


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