Payers Solutions

With the medical loss ratio (MLR) mandate, it’s more critical than ever for health plans to increase the quality of administrative functions while lowering costs. CITI provides the full spectrum of healthcare transaction processing services. Recognizing that these functions are essential for businesses to succeed but are also serious drain on resources, we can assume the day-to-day tasks to help streamline operations and allow our clients to focus on their core business and achieve profitable growth.

We utilize onshore, near-shore, and offshore processing centers around the world to offer round-the-clock, end-to-end service delivery. By combining of a number of discrete services, CITI can manage the entire content lifecycle and automate manual processes for improving access to, and the quality of, critical information. Our healthcare transactional services include:

  • Front-end
  • Image and data capture
  • Post processing
  • Payment services
  • Document and transaction content management

We provide end-to-end solutions for all operational towers including:

  • Claims processing
  • Membership and billing
  • Provider maintenance
  • Eligibility

Benefits

  • Improve data quality
  • Increase auto-adjudication rates
  • Fully compliant with HIPAA and other healthcare regulations
  • Accelerate turnaround time (TAT)
  • Enhance your bottom line
  • Combine our extensive domain knowledge, business rules engines and world-class operating model, and your health plan can achieve tangible results.

We're a leading provider of health plan administration and customer care services. Our dedicated Payer agents provide services that include:

  • Benefits Explanation and Verification
  • Claim Status
  • Complaints and Appeals
  • Disease Management Programs
  • Eligibility Verification
  • Enrollment Processing Services
  • Health and Wellness Programs
  • Licensed agent customer care services
  • Missing/Invalid Information Research
  • Payment and Benefits Explanation
  • PCP Change
  • Product/Services Information
  • Referral Requests and Status
  • Satisfaction Surveys

Enrollments and costs for health plans are expected to increase starting in 2014. Health reform expands eligibility and access to millions of new Americans through new vehicles such as healthcare insurance exchanges (HIX) and through regional Co-Ops. In order for these health plans to be successful, they must contain costs while being efficient and improving outcomes over their rivals.

In the evolving healthcare environment, health plans and the programs they serve will be graded and rewarded based on improvements to the member's health status. Our third-party administration (TPA) services give health plans and Co-Ops the flexibility to do more for their members while reaping significant financial dividends under the right operating structure.

Some of the primary third party administration services provided include:

  • End-to-end system operations: from enrolling new members to processing their claims
  • Customer communication: multi-channel capabilities that include member and provider call centers, outbound mailing, electronic document delivery (eDelivery) and compliance with the summary of benefits and coverage (SBC) mandate
  • Integrated care management: quality management and utilization review
  • Recovery services: a full spectrum of fraud, waste, and abuse detection and prevention
  • Financial management: billing, payment processing and reconciliation
  • Credentialing and contracting

Additional third party administration services that can be integrated include:

  • Plan design
  • Electronic data interchange (EDI)
  • Long-term care management
  • Provider relations management
  • Analytics and reporting
  • Underwriting
  • PBM services

Our TPA services give health plans the ability to rapidly scale so they can meet the uncertain demands of healthcare reform, allowing them to focus on providing better services to their members and use healthcare reform as an opportunity to grow their business.