BPO – Business Process Outsourcing Services
For the healthcare industry, the digital economy demands that organizations run better. The challenges include innovating, providing effective member-friendly services, streamlining and automating processes, containing costs, and increasing membership.
Technology can go a long way to help businesses achieve these goals. But taking it the rest of the way requires deep expertise in both healthcare and technology, along with mature services that deliver on their promises. Our integrated, end-to-end BPS solutions help your organization:
- Improve processes, increase efficiency and reduce costs.
- Innovate and compete more effectively.
- Grow and retain membership, boost profitability and drive revenue growth.
Care & Quality Management
Qualexa has a highly trained and knowledgeable team of Medical Professionals.
We are skilled in providing Care, and Quality Management delegated services in:
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- Utilization Management
- Case Management
- Disease Management
- Quality Management
Contract Management
Payer & provider and administration contract negotiation.
Contract negotiations are critical to the healthcare system. Qualexa’s team of professionals know how to analyze, initiate, and compare contracts to negotiate the best rates for your organization.
Our team makes it look easy, but negotiations can be intense and time consuming. Our contract management services are designed to remove annoyances caused by endless paperwork and applications.
We follow payor contracts from initiation to execution ensuring contracts are active, include all products, and providers are successfully linked to them.
Credentialing Administration & Management
The Qualexa team gives you peace of mind to focus on the safety and wellness of your patients by using its extensive experience and expertise to deliver highly responsive, accurate and cost-effective credentialing services. Qualexa Healthcare understands Credentialing and Contracting can be incredibly challenging and time-consuming for providers and new organizations. We manage all aspects of intricate credentialing, provider enrollment, primary source verification and more as we are an extension to Human Resources, Credentialing Departments and Medical Staff Offices.
Qualexa is your one-stop shop for a full spectrum of Credentialing Services, whether you are a solo independent practice or a National Health Care Delivery System.
Primary Source Verifications (PSV) for:
- State Medical License
- Controlled Dangerous Substance License (CDS)
- Drug Enforcement Agency (DEA)
- Board Certifications
- Medical & Professional Education
- Internship, Residency, Fellowship
- Hospital Affiliations
- Work History
- Malpractice & Claims History
- Ongoing License Sanction Monitoring
- Medicaid & Medicare Sanction Monitoring
- National Practitioner Data Bank (NPDB)
- Council for Affordable Quality Healthcare (CAQH)
- Initial
- Maintenance and Updates
- National Provider Identifier (NPI) Registration
- Initial Registration
- Maintenance and Updates
Contract Management & Provider Enrollment
It is essential to understand that the process of Credentialing and Contracting requires time, which can take four to six months to complete.
Few instances may shorten this time, but not often. Our team communicates with payers regularly confirming Credentialing is actively
taking place, maintained and current. Additionally, Credentials need to be reviewed and updated for contract compliance and privileging purposes.
Completion and submission of Provider Enrollment Applications with:
- Commercial – Group and Individual
- Medicaid and Medicare – Group and Individual
- Medicare and Medicaid Revalidations
- Payer Follow Up
- Payer Contracts
Hospital Privileges
We can also provide Contract Management Services for all of your personnel.
Eligibility & Benefits Administration
Benefits and Claims Administration
- Comprehensive Insurance and Managed Care Benefits and Contract Management
- End-to-end Claims Cycle Processing and Adjudication
- MSO/Claim administration
- TPA Services
Healthcare Consulting
Transform Care with Valued Experience
Healthcare organizations can manage, optimize and transform their businesses to new, efficient business models with our consulting expertise.
TPA Services
Qualexa Services offers Third Party Administrator services, Claims Management, Managed Care and Risk Control solutions for its clients.
Claims Management
Qualexa strives to offer an integrated approach to claims management that will shorten claim duration, reduce overall claim costs, and ensure that beneficiary members receive the medical care they need to return to full health. We assess and counteract issues that delay claim closure through innovative technologies and a dedicated plan of action.
Qualexa TPA Services
Qualexa Services offers Third Party Administrator services, Claims Management, Managed Care and Risk Control solutions for its clients.
Qualexa strives to offer an integrated approach to claims management that will shorten claim duration, reduce overall claim costs and ensure that beneficiary members receive the medical care they need to return to full health. We assess and counteract issues that delay claim closure through innovative technologies and a dedicated plan of action.
Value-Based Care
Value-based payment can be a winning proposition so long as an organization has all the right pieces in place.
In the new era of value-based payment contracts, health systems will require a business and clinical model designed to help them assume increased risk. If value-based payment contracts with a health system’s sponsored Accountable Care Organization (ACO), our Clinically Integrated Network (CIN) is to be more than simply the next incarnation of pay-for-performance, they must lay the groundwork for a comprehensive population health management strategy, with all the pieces in place to manage the cost of care effectively.
Balance the use of traditional and new metrics.
The challenge for most health systems pursuing the value-based payment model is that they must do so while continuing to operate in a fee-for-service (FFS) world. That means they must continue using traditional FFS metrics focused mainly on volume while also developing new metrics and skill sets, such as:
- Analyzing measures such as episodes of care for chronic conditions, utilization rates and practice pattern variations, deviations from care pathways and errors in outcomes reporting.
- Becoming proficient in benefit design, product pricing and curation of care networks.
- Understanding how the benefit design and payment rate changes described in the contracts will affect utilization rates and financial performance.
