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Medesis [Shared]

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Ali Alatas

on 8 February 2017

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Transcript of Medesis [Shared]

Our Story
Our Medesis values originated in 1982 when Dr. Sidney J. Stern began his career in managed care. After founding an eye care network with only 15 providers in South Florida, Dr. Stern grew the network into one of the largest, most successfully managed in the state of Florida. In 2001, with a proven track record, he developed his processes into a proprietary managed care software platform.
Our core values are to develop and adopt exceedingly efficient practices and innovative technologies in order to increase our viability as well as that of our partners. With more than 30 years in the health care industry, the core values of Medesis Health Systems make the identity and culture of our company. These values set us apart as a leader in providing excellent and Innovative Solutions for today’s healthcare payer. 

Our dedicated staff adheres to the principles that set us apart – listening to our clients, learning what they need, understanding their challenges, and providing tailored solutions. We continue to integrate proven practices and advanced technology
with customizable
support, service,
software solutions,
and commitment to
our clients.
Healthcare Organization
, also known as Payer, subcontracts
Specialty Provider Network to manage their patients and
their benefits.
Independent Physicians
are subcontracted by Specialty Provider Network to render care of its patients.
Third Party Administrator
, also known as TPA, is subcontracted by Specialty Provider Network to manage administrative processes.
Specialty Provider Network Landscape
Home Health
Home Infusion
Durable Medical Equipment
Mental Health
Radiation Oncology
PT, ST, OT (Therapies)
Pain Management
General Surgery
Our Integrated Ecosystem
Claims at a Glance
Healthcare Organization Partners
Specialty Provider Network Partners
Industry Partners
Here's what our customers have to say
“Humana has successfully partnered with Dr. Stern’s organizations in Florida for more than 30 years. I highly recommend his organization and his team.”
Stephanie Steele-Nelson
Vice President, Provider Partnerships
“Medesis is more than just a vendor. We see them as one of our most valued partners”
Dannielle Dixson
Program Manager
Miami Lighthouse
“They are very quick to answer and handle issues that may come up.”
Dr. Daryl Gershbein

Founder & Owner
Miami Foot Center
“Always enjoy working with the Medesis team due to their teamwork & professionalism.”
Francine Orta
Market Director, Network Operations
“My interactions have always been outstanding.  The assistance, cooperation, team work, accommodation of requests, professionalism has  always been unsurpassed.”
Lourdes Aguilera

Client Relationship Manager
“We appreciate your efficiency. If only all clients were like you!”
Hazel Lopes
Implementation Manager
“This group has brought countless value to Coventry. The employees address matters quickly, efficiently and thoughtfully. ”
Travs Butler

Director Network Management
“Working with you has
been a pleasure. Your team always comes thru.”
Stan Silverman

Director of Transportation
“We congratulate Medesis for consistent commitment to maintaining the highest standard possible. 99.41% clean claim rate. Wow!”
Matt Blandford

Client Manager
Questions ?
Thank you
Customer Service
Call Tracking
Log and Track Modifications
Comments and Documentation
, diagnostic, pharmacy, eyeglass labs, etc used to provide patients with particular product benefit.
Specialty Provider Network
, also known as Line of Business (LOB), coordinates all the entities involved in the healthcare program.
As a licensed Third Party Administrator, Medesis Health Systems has provided proprietary managed care software and processes since 2007. Today, we continually add value to our clients across many disciplines in the health care industry, implementing the same quality services and success to specialty managed care provider networks in the country.
Values & Vision
Company Overview
Values & Vision
Managed Care Universe
Medesis by the Numbers
eHealthdeck Platform
Benefit Plan Administration
Multi-Option Plans
Fully Integrated with Claims and UM
Accumulators, Exclusions and Limitations
Co-pays, Deductible and Co-insurance
Reimbursement Management
Complex Reimbursement Methodologies
Eyewear Product Chargebacks
Provider - RVU, Unique Patient, Fee for Service
Facility - Per Diem, DRG, Discount Percentage
Capitation Module - PMPM, PCP/Specialist, Age/Gender
Membership Management
COB - Primary and Secondary
Automatic Retroactive Enrollments and Disenrollments
Profiles to control consistent Membership and PCP Changes
ID Card Print Capabilities
Payer Management
Healthcare Organizations, HMOs, MSO, Non-For-Profit Organization, Self Insures
Lines of Business support Medicare, Medicaid, Commercial and Health Kids
Support of multiple Groups and Plan combination
Member Bank Account Management
Authorize and pay claims from member-level accounts
Real-time balance information includes optional Line-of-Credit
Adjudication includes real-time balance calculation for accurate payment amounts
Full system provider/facility reimbursement suite or specialized discounts available
Claims Management
CMS1500, UB04, Pharmacy
Auto Adjudication
Repricing and UpPricing
Fully integrated with Optum’s Claims Edit System
NCCI, CMS Guidelines and Global Compliance
Customized Preferred Practice Patterns by specialty
Utilization Management
Fully Integrated with Claims
Referrals / Authorizations
Multiple Providers and Multiple Levels of Care Attached to One Authorization
Automated Cost and Savings Calculations
HIPAA Profiler allows users to setup and control EDI senders and receivers
The HIPAA Import module manages all inbound transaction sets. One program; no confusion!
Receive and process transactions directly or through your clearinghouse of choice
Case Tracking
Links Multiple Referrals and Authorizations Under One Unique Case Identifier
Performs Automated Case Tracking by Diagnosis and Procedure
Time Accounting
Clinical Guidelines
Integration capable to Commercial Data Base (Interqual, MCG, etc)
Provider Management
Supports Multiple Plans with Multiple Reimbursement Arrangements
Accommodates Multiple Practice Locations and Tax ID Numbers for Each Provider
Calculates capitation Enrollment Online for a 24 Month Period per Provider
Comprehensive Provider Directories
Provider Panel Management
Provider Credentialing Functionality
Customer Service
Call Tracking
Log and Track Modifications
Comments and Documentation
Premium Billing
Associations, Groups, Family, Individuals
Multiple Billing Periods
Financial Management
Interfaces with Commercial Accounting Packages
Broker / Agent Commissions
Provider Check Generation
1099 Generation
Centralized Data Mart
Standard Reports Package
Ad Hoc Reports
Custom Reports
Dashboard Reporting
Report Delivery Automation
Web Portal
Eligibility and Benefit Verification
Provider In-Network Verification
Authorization Requests
Claims Submissions
Eyeglass Order Submission
Claim and Eyeglass Order Status
Explanation of Payment Downloads
Benefit Plan Pages
Resources and News Section
Role Based Access Control
Unified Communication Platform
Find a nearest Provider
HEDIS Programs
Optometry Reports
Auto Fax Scheduler
HEDIS Gap Data Validation
Telemedicine Portal
Integrated Patient Records
Remote Image Uploads
Physician Review Reading Center
Insight Outreach Campaigns
Laboratory Management
Eyeglass Order Routing
Frame Kit Selection Options
Lens Combination Selection Options
Secure Data Sharing
Secure File Transfer Protocols
Open Automated Program Interfaces
Audits and Delegations
Claims Delegations
Credentialing Delegations
Utilization Management Delegations
Customer Care Delegations
Corporate Compliance
Unified Communications
Secure Intranet
Send & Receive messages between physicians & the departments to increase efficiency & automation.
Receive message notification by email or text
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