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IPA Grows Medicare & Medicaid Business by 12% with Better Payment & Utilization Management Software

When a West Coast IPA wanted to expand their Medicare and Medicaid business lines, they turned to Cedar Gate. Our advanced claims processing, care management, and utilization management tools helped streamline operational efficiency by automating complex administrative processes and identify care opportunities.

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Expanding Medicare & Medicaid Business Lines While Navigating Regulatory Compliance

When a West Coast independent provider association (IPA) wanted to expand their Medicare and Medicaid business lines, their focus turned to creating more efficient care and utilization management processes while streamlining core claims administration. The goal to capture market share exposed the growing organization to new challenges. Key among those challenges was figuring out how to support a large, geographically dispersed provider network and a diverse member population. The complex regulatory environment related to CMS business lines meant the organization needed to scale their clinical and administrative workflows. They also had to ensure compliance with time- and language-sensitive contractual requirements.

The IPA achieved sustainable growth and expansion using Cedar Gate’s claims processing and care management capabilities, which maximized efficiency and eliminated the need to hire additional staff.

Addressing Operational Efficiency to Remain Profitable During Expansion

The IPA’s strategic objectives included growing market position and improving administrative and care management efficiency with Medicare Advantage and Medicaid populations. The organization would have to improve operational efficiency to maintain profitability. That was especially true given the complex regulatory and compliance requirements involved in state Medicare and Medicaid programs.


Software Provides the Tools to Automate & Evaluate New Programs

Automation has increased efficiency in numerous industries, but healthcare has lagged behind. However, staffing shortages and increased administrative and regulatory demands are changing that for many healthcare organizations. The IPA worked with Cedar Gate to identify tools that could automate some of the time- and labor-intensive processes involved in Medicare and Medicaid administration, and evaluate performance to uncover opportunities for improvement.

Automate Pre-Authorizations, Referrals, & Letters

To manage a diverse population with strict requirements for communication mode, frequency, and language, the IPA leveraged automated pre-authorization and referral workflows. They also implemented our robust letters management module that supports communication for multiple utilization management processes. A connected portal makes it easy for provides to initiate and monitor the authorization process, and minimizes delays.

Evaluate Care Options

As organizations expand services to Medicare and Medicaid populations, they must be able to identify unique needs for these patients, and provide care that improves quality and outcomes. Cedar Gate’s extensive tools make it easy for care managers to access member information. This helped the IPA evaluate all the available care options and identify ways to reduce health risk. This information also helped them develop more effective care plans.

Automate Claims Adjudication

The IPA also used Cedar Gate’s Capitation Adjudication software to centralize core claims administration and management. It provided secure data transmission from network clinics to the IPA, with processes configured to run automatically so there was no need for manual oversight. The IPA could manage multiple provider contracts under a single ID to track and administer payments based on contract parameters, all without hiring any additional staff.


Administrative Efficiency Leads to Sustainable Growth

Cedar Gate’s tools helped the IPA achieve its goals of expanding its Medicare and Medicaid lines of business by streamlining administrative processes and increasing efficiency. That included:

  • A 10% increase in claims processing efficiency
  • Addition of two health plans, resulting in 12% membership growth
  • 33% growth in the provider network without hiring additional staff


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