CA- Org Streamlines Billing, Authorizations in Public Payer Coverage

[MM Curator Summary]: A CA MCO is investing in its tech stack to improve services to members.


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CalOptima sought to make claims processing and prior authorizations more efficient for members with public payer coverage by revamping its technologies.


Source: Getty Images


By Kelsey Waddill

March 30, 2022 – CalOptima—a county-organized health system that offers care through public payer coverage, including Medicaid, Medicare Advantage, and Medicare-Medicaid plans—is launching a five-year strategy to streamline claims reimbursements and authorization processes.

“As the single largest health plan in Orange County, CalOptima provides care for one in four residents. We take that enormous responsibility seriously, and our members are counting on us to help them access the right care at the right time,” said Michael Hunn, chief executive officer of CalOptima.

“Automated technology will allow members to receive same-day authorizations, helping them access needed treatments and specialist care on a timely basis.”

CalOptima will dedicate $100 million to the new strategy, which will go toward acquiring new technologies and establishing a health information exchange. The organization will take a cloud-first approach, which CalOptima assured would be HIPAA compliant and armed against cyberattacks. 

According to CalOptima, this move will make the organization the first in California to adopt real-time claims processing technology for the state’s federal Medicaid program.

“The changes articulated in the new vision will help reduce delays and barriers to care for our members, as well as attract more providers to work with CalOptima,” said Supervisor Andrew Do, chair of the CalOptima Board of Directors. “Understanding the life changes in our members will also allow CalOptima to help our members address insecurities in their daily needs that may impact their physical and mental health.”

The organization has modified its mission and vision statements to encompass these goals. The mission statement revolves around upholding human dignity, and the vision statement stretches into 2027.

“By 2027, remove barriers to health care access for our members, implement same day treatment authorizations and real-time claims payments for our providers, and annually assess members’ social determinants of health,” the new five-year vision explains. 

In addition to the $100 million investment, CalOptima will also dedicate $8 million to a program that will launch through the Orange County Interagency Council on Homeless Health Care (OCICHHC). 

OCICHHC brings together CalOptima and other healthcare stakeholders to address homelessness in Orange County, a region that experienced one of its highest death rates in the homeless community in 2021.

In response, OCICHHC launched a street medicine program. The program sends healthcare professionals and social workers in mobile teams out into the streets of Orange County to meet homeless individuals and connect them with necessary treatments. These efforts directly target the high mortality rate in Orange County’s unhoused community.

“The health care crisis among our homeless population has been a significant challenge,” said Supervisor Doug Chaffee, chairman of the Orange County Board of Supervisors and CalOptima board member. 

“However, we are moving in a proactive direction by forming the Street Medicine team, which will assist our Medi-Cal members who are experiencing homelessness. A vast majority of our homeless Medi-Cal members lack access to medical care, and this team will help address the need by eliminating barriers and linking them to much needed medical care and social services. My hope is that this initiative will help reduce the number of mortalities among the homeless population.”

Other board members applauded the investments in technology, citing the impact these advancements and the street medicine program could have on Orange County community health. They also noted the influence that the street medicine program could have by reducing barriers to access to care.

While CalOptima has tackled healthcare for the homeless through Medicaid coverage, other payer industry leaders have supported using Medicare Advantage special needs plans to provide access to care for the homeless population.

Other payers leverage community data to guide their philanthropic investments for the unhoused community.

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