GuideWell Source, a GuideWell Mutual Holdings Corporation
- Headquarters in Jacksonville, Florida
- Medicare Administrative Contractor 3,000 employees
- 11M insured
- 500,000 healthcare providers
The Business Environment:
GuideWell Source is a leading administrative services company providing full-service, administrative business solutions for health programs. Headquartered in Jacksonville, Florida, GuideWell Source is the corporate shared services and parent company of its wholly owned subsidiaries First Coast Service Options, Inc. (First Coast), Novitas Solutions, Inc. (Novitas) and GuideWell Allegiance, Inc.
Guided by our values of doing the right things, the right way, the GuideWell Source family of companies is committed to conducting business with integrity and operational excellence while continuously improving our organization and business processes and providing fiscal responsibility in service to our customers. Our family of companies has strong relationships with business partners like the Centers for Medicare and Medicaid Services (CMS); deep traditional Medicare knowledge, and strong program management capabilities necessary to service health plans, payers and government sponsored health care programs.
The Office of the Actuary Centers for Medicare & Medicaid Services cites spending by governments (Federal, State and local) reached $1,266.3 billion in 2013 and accounted for 43 percent of total health spending, an increase from a 32 percent share in 1987, mainly due to growth in the Medicare and Medicaid programs. Together, Medicare, Medicaid and CHIP spent $1.0 trillion for health care goods and services in 2013—36 percent of the country’s total health care expenditures. For 2014 through 2024, national health spending is projected to grow at an average rate of 5.8 percent annually, a 1.1 percentage point faster than the expected annual increase in GDP over the same period. As a result, the health share of GDP is projected to rise from 17.4 percent in 2013 to 19.6 percent by 2024. National health expenditures are projected to reach $5.4 trillion in 2024, up from $2.9 trillion in 2013. Health care spending financed by Federal, State and local governments is projected to represent 47 percent of national health expenditures by 2024, up from 43 percent in 2013, with total government spending projected to reach $2.5 trillion. Rising government spending on health care is expected to be driven by expanded Medicaid coverage.
“M2 Systems’ reputation for rapid deployment and flexibility, as well as their HIPAA-ready solutions, gave us the confidence to move forward quickly.”
– Harvey Dikter, President and Chief Operating Officer of GuideWell Source
GuideWell Source’s vision includes maximizing market share and delivering exceptional service to a diversified customer base. This aligns with the innovating and changing marketplace of health care solutions. We will achieve this through leveraging our deep knowledge and relationships as well as our core capabilities and remaining true to our mission of providing best value administrative service.
Critical Issue (Challenge):
In order to realize its corporate vision, GuideWell Source needed a commercial off-the-shelf solution to secure a coveted position as a Medicare Administrative Contractor (MAC). Their hardware architecture had changed over the years from the “Stratus” to more commercially available and price competitive platforms such as Linux. This and the looming HIPAA 5010 requirements spurred Guidewell Source to look to M2 Systems Corporation, recommended by CMS as a desirable vendor, to provide the platform to support the change in hardware architecture and meet the new HIPAA requirements.
The following critical Business Issues needed to be addressed:
- More functionality than previous product supported
- Quick turnaround time to deploy the solution
- CMS indicated a strong desire for all MACs to move toward more “common” solutions with M2 Systems being one of the limited vendors recommended by CMS for this goal.
- Requirements to meet HIPAA regulations, current and future
- Desire for an experienced vendor in this segment
- Cost management
Vision:
After six-months of vendor evaluations, M2 Systems Corporation was selected to deliver healthENGIN©, its flagship “all-payer” EDI solution. M2 Systems was currently processing Part A & B claims for the 2 largest MACs and was the first HIPAA compliant solution on the market implemented into production. “M2 Systems’ reputation for rapid deployment and flexibility, as well as their HIPAA-ready solutions, gave us the confidence to move forward quickly” says Harvey Dikter, President and Chief Operating Officer of GuideWell Source. Dikter continues “M2 Systems’ knowledge and experience of the health payer market was extremely valuable to us.”
The Solution:
M2 Systems provided an intelligent messaging infrastructure that delivers a single-source solution for connectivity, translation and interoperability in a scalable, flexible, cost-effective and proven all provider, all payer, all transaction system. healthENGIN© processes EDI and proprietary health care claims, payments, eligibility and payment inquiries, submits patient information safely across networks, and enables full HIPAA standards compliance including the latest 5010 transaction set.
healthENGIN© Provider Portal provides the ability for self-provisioning and on-boarding by providers and trading partners. Administrative controls ensure proper security, credentials and user roles that meet HIPAA requirements. DDE, self-certification, secure file upload/download and other features of the healthENGIN© Provider Portal all add a value to the service offerings of GuideWell Source that are unparalleled.
heatlhENGIN© from M2 Systems Corporation
Diana Haramboure, Senior Vice President and Chief Administrative Officer for First Coast Service Options Incorporated (FCSO), a wholly-owned subsidiary of GuideWell Source, says “The ability to efficiently manage the business requirements mandated by CMS and maintain high-quality provider relationships is paramount for the success of GuideWell Source”. healthENGIN© is used to acquire, edit, secure, and route institutional and professional claims for adjudication. With over 50 million claims per month, accuracy and efficiency could not be compromised. “M2 Systems demonstrates agility and simplicity allowing our business analysts to quickly and easily support our providers and CMS. We have reduced administrative costs in many areas as a result of our partnership with M2 Systems” says Haramboure.
“The ability to efficiently manage the business requirements mandated by CMS and maintain high-quality provider relationships is paramount for the success of GuideWell Source.”
– Diana Haramboure, Senior Vice President and Chief Administrative Officer for First Coast Service Options Incorporated (FCSO), a wholly-owned subsidiary of GuideWell Source
The foundation for healthENGIN© is Enterprise Generic Integrator (ENGIN©), M2 Systems’ high-performance integration platform. “With ENGIN© as an IT asset, GuideWell Source is positioned to expand our business through new channels, new interfaces and efficient use of our IT infrastructure” says Mike Orenchuck, Vice President and Chief Information Officer at GuideWell Source.
The Results:
healthENGIN© from M2 Systems Corporation provides the GuideWell Source family of companies, First Coast and Novitas, with administrative and claims processing services for state and federal health care programs such as Medicare. First Coast and Novitas contract with CMS to provide quality Medicare administrative services throughout the United States to more than eleven million beneficiaries and the five hundred thousand health care providers who care for them. The services provided include claims processing, customer service, appeals adjudication, education and outreach activities, and functions that help promote the integrity of Medicare program payments. First Coast is the Part A and Part B MAC for Florida, Puerto Rico and the
U.S. Virgin Islands (Jurisdiction N). Novitas is the MAC for Delaware, District of Columbia, Maryland, New Jersey and Pennsylvania (Jurisdiction L) as well as Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma and Texas (Jurisdiction H). As MACs, First Coast and Novitas represent approximately one-third of the entire Part A and Part B Medicare landscape.
The benefits of healthENGIN©
- Meet CMS requirements
- Commercial Off-The-Shelf System
- Maintain HIPAA complianc
- Provide a foundation for growth, acquisition and new requirements
- Lower total cost of ownership due to efficiencies and performance
- Less labor intensive through the use of intuitive mapping and editing technology
- Expedited deployment with no application programming required
- Features not available at all from other vendors, or requiring IT staff to perform as opposed to business staff.
- Web-based User Interface
- More user friendly than other products reviewed
- Much faster setup of Trading Partners
- Improved customer (provider) services with healthENGIN© Provider Portal
healthENGIN at a Glance
HIPAA
- 5010 c0mpliant Payer Specific
- NCPDP
EDI
- ANSI X12
- Clearinghouse
Payer Specific
- Trading Partner Management
- All-payer Any-to-Any
Proprietary
- Legacy Systems
- Custom Edits & Rules
In a recent Modern Healthcare article, January 29, 2016, Andy Slavitt, Acting Administrator for the Centers for Medicare and Medicaid Services (CMS) says “Increasing access to analyses and data that include Medicare data will make it easier for stakeholders throughout the health care system to make smarter and more informed health care decisions.”
Why M2 Systems Corporation:
EXPERIENCE
- In business since 1986
- 30+ years & running with health care & financial customers
SAVINGS
- Remarkably low total cost of ownership
- Twice the performance, half the hardware costs
SPEED
- Industry leader in rapid time-to-market delivery Up and running in 45 days…guaranteed!
INNOVATION
- First to market
- Clearinghouse & EDI Gateway Solutions since 1993 HIPAA – first production implementation
PERFORMANCE
- Fast, flawless and reliable throughput for both batch and real-time solutions
- 3 largest Medicare intermediaries by volume
- 3 largest payment processors in U.S. Largest bank in U.S.
About M2 Systems Corporation
M2 Systems specializes in developing, marketing and implementing transaction technologies for both established and emerging markets as well as creating outlets for licensing and operating its solution sets. We have developed a firm foundation in several vertical markets, including health care and financial payments, with significant and positive financial and operational impact to the overall organization. With a 30-year track record of architecting, developing and implementing highly scalable transaction processing software and managing hundreds of millions of transactions yearly, M2 Systems is widely recognized as the gold standard in performance engineering and delivery systems.
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