Healthcare operations should not be a constant challenge for providers, administrators, and patients. We’ve all experienced what it’s like when systems and processes are not working as hoped and the experience becomes unbalanced. This puts strain on every entity, at a moment when a frictionless experience is what is needed most. This is our passion and our pride—to deliver a frictionless, empowering healthcare operation that benefits all.

Healthcare Operations

We help health plans, administrators, hospitals, and providers improve patient experience and program performance through system and process optimization.

Garnet River Healthcare Operations Practice Lead

“We started Garnet River Healthcare because of the growing need for organizations to meet regulatory standards through effective monitoring and oversight. Our approach is 360, and success for us is ensuring you have the right people, processes, and technology to maintain standards and and operate with sustainable excellence.”

Courtney Seypura, Practice Lead

  • Health Carrier Uses Reg Matrix to Increase CMS Star Rating

    After a CMS audit identified CAPs for a health carrier with 4 million members, we developed a Regulatory Matrix and helped mitigate and get CMS approval for all CAPs. Approximately 75 findings were identified with proposed solutions. The plan's CMS Star Rating increased by 1 point in most categories and an overall star rating of 4.5

    Categories: Case Studies, Healthcare, Legal & Risk Management

  • Are you CMS program audit ready for 2024

    Open enrollment activities are a true performance test of your company’s systems and processes. Garnet River Healthcare can get you 2024 CMS program audit ready.

    Categories: Healthcare, Thought Leadership

  • CMS releases updated Plan Communications User Guide (PCUG)

    CMS released the updated PCUG 17.4v for Medicare Advantage and Prescription Drug Plans. Changes are minimal, but the release is always a good time for you to revisit what you're doing.

    Categories: Healthcare, Thought Leadership

  • Medicaid and CHIP eligibility

    On August 30, CMS sent a letter to all 50 states, requiring a review of their eligibility systems. The impetus for this letter: CMS determined some states’ Medicaid and CHIP eligibility systems are incorrectly configured.

    Categories: Healthcare, Thought Leadership

  • Part C & Part D Enrollment and Eligibility Guidance

    On August 15, CMS released the updated guidance for Part C and Part D enrollment and eligibility. Included with the policy and technical changes was a new MA model enrollment request form.

    Categories: Healthcare, Thought Leadership

  • Annual Election Period must-dos for Medicare Advantage Plans

    To prepare for Annual Election Period, Medicare Advantage Plans and BPOs need to do more than cover cost and treatment. They need to elevate member experience.

    Categories: Healthcare, Thought Leadership

  • Increase your CMS star ratings

    From 2022 to 2023, ratings for MAPs have dropped, with less than half of plans receiving a good rating. Here's you you can increase your CMS star ratings.

    Categories: Healthcare, Thought Leadership

  • Is your CMS program audit ready for 2023

    Open enrollment activities are a true performance test of your company’s systems and processes. Garnet River Healthcare can get you 2023 CMS program audit ready.

    Categories: Healthcare, Thought Leadership

Why Garnet River Healthcare

We help you work smarter, not harder. Garnet River Healthcare’s subject matter experts have over 35 years of industry experience. Our proven methodology focuses on people, process, and technology. And we leverage unmatched data analytics to optimize your operations and systems…yielding cost savings and successful audit outcomes.

We support: Health Plans, BPOs, CCBHCs, TPAs, State Public Sector & Federal Organizations, Hospitals, Healthcare Service Providers, ACOs.

Areas of Specialization

New Program Start-Up & Expansions ~ Business Process Improvement & Operational Excellence ~ Program & Vendor Oversight ~ Compliance, QA/IVV ~ Medicaid & Medicare ~ Compliance Repository

Case Studies

State health department introduced innovation to database and reporting tools

Health carrier uses Reg Matrix to increase CMS Star Rating

State DOH contracts for quality assurance to ensure compliance with CMS guidelines

Service Offerings

What We Do

Develop and implement:

  • Regulatory Matrix to establish operational and system requirements in accordance with CMS/State regulations
  • Functional area workflows
  • Business and system requirements
  • Functional area test case scenarios
  • CMS/state/vendor data file exchanges
  • Policy and procedures
  • Desktop Level Procedures (DLPs)
  • Training materials for functional areas
  • Regulatory and Internal Operational Reporting
  • Executive Dashboards
  • Audit universe development and testing
  • Post go-live support

Client Outcomes

Proven Results:

  • Compliant operations aligned with CMS and state regulations
  • Effective operational processes and controls
  • Successful regulatory audits
  • Reduced risk of non-compliance findings
  • Regulatory reporting readiness
  • Program insight at executive and operational levels
  • Resources that are prepared, confident and knowledgeable for go-live support
  • Reduced risk of member and provider complaints, appeals, and grievances

What We Do

Identify:

  • Operation and System Compliance Risks
  • Resource Utilization Constraints
  • Process Gaps and Remediation to enhance Operation and System automation
  • Provider Network Set Up and Configuration concerns
  • Insourcing and Outsourcing opportunities to increase company revenue and process efficiencies
  • Interdepartmental data exchange deficiencies

Implement:

  • Early warning sign strategies to minimize Operation Inventory backlog
  • Robotic Process Automation (RPA)
    • Repetitive Simple to Complex Tasks
  • Validation tools to ensure accurate Provider Configuration, Contract Rates, and Provider Data

Client Outcomes

Improved:

  • Eligibility determination
  • Eligibility data accuracy and processing time
  • Claims payment accuracy and processing time
  • Appeals and Grievances processing time
  • Provider Network claim pends and adjustments
  • Provider match rate and payment accuracy
  • Provider Credentialing processes and OIG Check
  • Quality of products delivered to patients and members
  • Member, Provider and Patient satisfaction
  • Regulatory reporting
  • Operations and leadership reporting
  • Seamless interdepartmental data exchange

What We Do

Identify:

  • Compliance Risks
    • Regulatory
    • Contract Service Level Agreements (SLAs) and Performance Guarantees (PFGs)
    • Data Exchange Gaps and Remediation efforts

Implement:

  • Reconciliation tools to reduce the risk of Data Discrepancies
    • Eligibility
    • Provider
    • Claims Payment
    • Encounters
  • Audit Universe Validation
  • Payment Integrity & Program Validation Tools

Client Outcomes

Proven results:

  • Empower our clients to control costs
  • Reduce risks to ensure effective service delivery
  • Improved Program outcomes, Managed Oversight and Quality Controls
    • Compliance and Data Exchange Integrity
    • Member and Provider Network satisfaction
    • Claims payment accuracy and timeliness
    • Appeals and Grievances accuracy and timeliness
    • Plan Payments and accurate Risk Adjustment Factor Scores (RAF)
  • Increased Audit Universe Data Integrity
  • Improved Fraud, Waste and Abuse Detection

What We Do

Identify and implement:

  • Standardized processes and tools to support/create:
    • Ongoing Quality Assurance Program
    • IV&V Program
    • Regulatory Reporting
  • Perform Mock Audits:
    • Determine Compliance Risks to prevent future Regulatory Corrective Action Plans (CAPs)
    • Identify Cross Functional Process Improvements
  • Audit Support:
    • Review/Develop Audit Universes
    • Prepare Responses to Audits and the documentation requested
    • Develop, Execute and Oversight of Corrective Action Plans (CAPs)
  • Negotiate settlements as necessary

Client Outcomes

Proven results:

  • Reduced Audit findings and Compliance costs
  • Improved Process Controls affording smoother Regulatory Audits
  • Alignment with CMS and State Regulations.
  • Increased CMS STAR Ratings
  • Established effective and repeatable oversight and quality control tools
  • Regulatory reporting readiness
  • Reduced Member and Provider Complaints
  • Decreased Appeals and Grievances
  • Identification of operational gaps
  • Opportunities for resource training
Garnet River Healthcare Products Practice Lead Megan Christiana

“By leveraging data-driven decision-making and cutting-edge technologies, we help organizations navigate the complexities of the healthcare landscape, ensuring they are equipped to deliver exceptional care while maintaining financial sustainability.”

– Megan Christiana, Healthcare Products Practice Lead 

Product Offerings

Offerings

This Medicare Eligibility and Plan Payment Reconciliation Tool that manages, reconciles, and reports the following CMS data files:

  • DTRR (Daily Transaction Reply Report)
    • Medicaid & LTI Indicators
  • MMR (Member Maintenance Report)
  • PPR (Plan Payment Report)
  • LEP (Late Enrollment Payment)
  • LIS (Low Income Subsidy)
  • Monthly Premium Withholding Report (MPWRD) Data File

Provides CMS with timely and accurate information regarding the beneficiaries’ enrollment, disenrollment, special membership status, and State and County Code changes.

Exports Reporting and Remediation/Aging tracking that summarizes:

  • Discrepancy type and aging
  • Plan vs CMS discrepancy
  • Timing issues
  • Research and remediation recommendations
  • Executed remediation actions

Retroactivity submissions (Category II and III)

Organization Benefits

Supports CMS required data processing in an efficient automated manner:

  • Daily and Monthly Reconciliation of the following Data:
    • Eligibility (incl. DTRR)
    • Plan Payment
    • Quarterly Attestations
  • Provides an effective tool to support identifying, tracking, and managing discrepancies between CMS and Plan Data to increase:
    • Eligibility and Plan Payment accuracy
    • CMS payment timeliness
    • Prompt remediation of eligibility and payment data discrepancies
  • Storing and updating of CMS Risk Adjustment Factor scores (RAF)
  • Identification of Operational Issues:
    • Processor
    • System Automation

Offerings

An Automated Regulatory Data Repository that stores, manages, and automates the upload for ongoing CMS and State Regulatory requirement updates and changes:

  • Updates Regulatory changes through an Automated upload to this Repository from any file format
  • Exports reporting that summarizes Process Change impact by Functional Area to allow for more efficient and timely operation and system changes to occur
  • Reporting will summarize the Operational changes required to meet the Updated/New Regulations

Organizational Benefits

  • Ongoing Financial Savings on Resources Costs to support these efforts
  • Reduces Compliance Risks Which Decreases CMS Financial Penalties
  • Streamlines Regulatory changes to maintain Compliant Operations and Service Excellence
  • Identification of Member/Provider Materials impact
  • Supports Training/P&P Material Creation and Updates to existing

Offerings

A Regulatory Matrix that is a one-time Export of the current CMS and State Regulatory requirements as of a point in time.

This can be provided to Organizations as the starting point to manage all CMS and State Regulations to maintain manually ongoing.

Organizational Benefits

  • One time Savings on Project Resource Costs
  • Establishes Compliant Operations for all Functional Areas
  • Initial Reduction of Compliance Risks
  • Affords the ability to create required materials while limiting internal research time:
    • Member and Provider Materials
    • Policy and Procedures
    • Training Material
  • Supports Workflow and Desk Level Procedure Creation Saving Resources Time and Costs.

Offerings

A Compliance Data Repository Tool that manages, reconciles, and reports Security Breaches and Privacy Issues:

  • Security Breaches and Privacy Issues
  • Training (Annual & up training) & P&P Tracking and Management
  • Operations Compliance Oversight, Monitoring & CAP remediation plan tracking, oversight & resolution
  • Mock CMS Audits

Streamlines Customized State and Federal Regulation reporting to different entities (HHS, CMS)

Compliance issues identification, tracking and management of Cycle Resolutions Timing and Aging, such as:

  • Employee terminations and re-hire and employee retraining
  • Member notifications
  • Member provided 1 year of credit monitoring
  • Media notifications
  • System corrections

Organizational Benefits

  • Centralized Compliance tracking tools allow for:
    • Reduced compliance issues due to increased awareness
    • Increased data integrity
    • Timely Remediation and Reporting
  • Support confirming all Organizational/Operational P&Ps are in place and updated annually
  • Support CMS reporting of Annual required Training and uptraining because of any CAPs initiated by Compliance, Compliance issue CAP Plan tracking, reporting & results monitoring
  • Report CMS mock Audit Results which assist Plans in identify how they would perform during a CMS initiated audit & assist with GAP identification and resolution

 

CareHerd is a mobile app for family caregivers that reduces the stress and increases the effectiveness of family care.

Caring for yourself or a loved one can be challenging, let alone organizing that care with family members, doctors, and other caregivers. We’ve combined the best caregiving tools into one app so you can spend more time with the people you love and less time on logistics, organization, and confusing search results.

> Visit the CareHerd website

Consa automates repetitive, time‑consuming tasks with AI to enable your clinicians to succeed. It relieves them of in-session note taking and assists in post session SOAP note formatting and submission for reimbursement- allowing them to focus on what they do best.

> Visit the Consa website

We deliver our RPA services on a project or program basis. Often, one or two successful projects lead to an RPA program that spans two or more functions. We prefer to start with a high impact process to demonstrate RPA’s power. The return on investment is usually easy to predict and increases as RPA is widely adopted. We have also helped clients develop their own internal RPA center of excellence.

> Learn more about our RPA offering