Case Studies

HMO Operations Integration – Large Medical Group

One of San Diego’s largest medical groups was integrating HMO operations of another large medical group. The transition needed to be complete by the cutover date. Multiple constituencies – patients, physicians and health plans – all had to be considered. Rasdal Associates was engaged to project manage the integration.

The first step was to put together an internal operating team for the integration with representatives from all of the functional areas. We also put together a joint operating committee with the medical group being integrated.

The following sub teams were formed:

  • Health Plan Contracting
  • Provider/Network Contracting
  • Provider Services/Network Management
  • Claims/Encounters/Enrollment
  • Credentialing
  • IT/Data/Security
  • Finance/Reporting
  • Utilization Management/Medical Management
  • Case Management/Complex Case Management/Disease Management
  • Anticoagulation/Medication Therapy Management Programs
  • Quality Management/Regulatory
  • Customer Service/PDRs
  • Marketing/Communications

The teams worked through the transition of billing, claims, authorizations, member relations, etc. over the course of several months. The clinical integration was designed to enhance clinical activities such as case management and disease management.

Integration was completed on time with no disruption to patient care. All constituencies – patients, physicians and health plans – were served appropriately and satisfied with the outcome. The integration has allowed more efficient utilization of resources and improved alignment of services for both medical groups.