Health Plan Invests $ 100M to Introduce Real-Time Claims Payments for Providers


What You Should Know:

– CalOptima will be the first health plan to introduce ‘real-time claims payments’ permanently for providers as part of this historic $ 100 + million investment in the safety net in Southern California.

– Board also approves $ 100 million in technology to improve health care delivery and $ 8 million to launch a Street Medicine Program.

CalOptima, a publicly funded health care coverage for low-income children, adults, seniors and people with disabilities in Orange County, California, today announced that its CalOptima Board of Directors unanimously approved a new vision for Medi-Cal member services that will change the delivery of health care for nearly 880,000 Orange County residents. The five-year strategic vision aims to remove barriers to health care access for members by implementing same-day treatment authorizations and real-time claims payments for providers, and annually assessing members’ social determinants of health.

Groundbreaking 5-Year Strategic Vision

To achieve this new vision, a $ 100M investment in technology advancements will not only allow CalOptima to provide same-day treatment authorizations and process real-time provider claims payments, but it will facilitate sharing critical data with community partners by developing a state-of -the-art Health Information Exchange program to break down silos and enhance care for members. When the system launches, CalOptima will become the first Medi-Cal plan in the state to implement real-time claims processing. CalOptima’s implementation of a “cloud-first” strategy will also include cyber-security controls to maintain HIPAA compliance and measures to prevent cyber-attacks.

Street Medicine Program

In response to the growing health care crisis among the homeless population, CalOptima and other agencies joined to form the Orange County Interagency Council on Homeless Health Care (OCICHHC) in December 2021. In conjunction with this partnership, CalOptima plans to launch the Street Medicine Program to support Medi-Cal members who are experiencing homelessness. Street Medicine will include health and social services designed to meet individuals where they are to reduce or eliminate barriers to care and follow-up services.

Street Medicine providers will work with CalOptima’s current Clinical Field Teams, outreach workers and mobile teams to address the needs of this population, linking them to a medical home in order to prevent emergency department utilization as well as the progression of untreated health conditions that may result in mortality.

“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.”

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