Southern California Physicians Managed Care Services offers a full range of management, administrative and financial services designed to assist physician groups in meeting and exceeding their growth and profitability goals. Clients may choose the full suite of services or they may select the individual services that best meet their needs.
Management Services
 Capitation, Accounting and Financial Reporting
Trained and experienced financial personnel manage all aspects of clients' financial needs, from accounting to financial analysis and customized reporting. Services include:
- Full service client accounting
- Monthly financial statements aggregated by individual health plan and product line
- Review of capitation revenue rates
- Provider capitation calculation and payment options
- Electronic deposit of primary care physician capitation payments
- Fee schedule maintenance – standard and custom by provider
- Stop loss insurance negotiations and management
- Directors and Officers/Errors & Omissions insurance negotiations
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Claims Payment and Encounters
Experienced analysts review claims according to standard processing guidelines and in concert with each client's specific needs and direction. Fully delegated by the contracted Health Plans for claims payment. Services include:
- CMS and AB 1455 compliant in claims, member denials, and provider dispute turnaround times and accuracy
- Advanced claims scanning system and electronic image storage
- HIPAA-compliant electronic claims submission available
- Timely processing and electronic submission of encounter data to health plans
- Virtual Examiner claims adjudication software
- Automatic application of benefits, including copayments
- Automatic application of health plan division of responsibility matrices
- Health Plan audits
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Client Services
Trained client services representatives are readily available to assist with operational issues and answer procedural questions. Services include:
- Telephone access
- Email access
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Eligibility and Benefits
Dedicated eligibility staff review electronic downloads and custom reports to assure accurate and timely eligibility information. Services include:
- Electronic eligibility for all contracted health plans
- Product line assignments by HMO, POS, Healthy Families, Senior, Medi-Cal
- Regional eligibility assignments available
- Eligibility audits to ensure accuracy
- Electronic benefit updates
- Reconcile capitation to eligibility
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Health Plan Contracting
Experienced contracting team reviews, analyzes and negotiates full risk and shared risk health plan contracts for all products. Services include:
- In-depth review and negotiation of contract language
- Recommendations for group network contracting adjustments
- Comprehensive analysis of financial terms and rates by product line compared to current performance
- Detailed negotiation of terms and rates; multi-year packages, as applicable
- In-depth review of delegation requirements. Fully delegated for credentialing, utilization review and claims.
- Quality Incentive Programs
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Information Technology
Our Information Technology Department supports SCPMCS operations with essential tools and services including advanced computer systems, telephones, fax and copy equipment. We maintain 99.9 % uptime record for our major systems. Services include:
- Safeguards for data provided through advanced technology, back-up and security systems
- Secure internet-based interface system that enables clients to automate numerous processes performed at their offices
- Electronic claims submission enables clients to submit claims directly to SCPMCS in HIPAA-compliant standard formats
- Hosting a provider-accessible web site that offers provider search capability, health plan affiliations, privacy and Medical Management policies
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Management Reporting
SCPMCS advanced systems enable the delivery of comprehensive standard reporting packages, as well as the development of customized reports for clients. Standard reports include:
- Health Plan and Provider Negotiations
- Health Plan/Product Line Performance
- Provider Adequacy of Compensation
- Costs by Specialty
- Costs by Primary Care Physician Assignment
- Client Services Telephone Activity
- Current Provider Listings
- Contracting Activity Reports
- Utilization Reports
- Admissions and Bed Days
- Emergency Room Utilization
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Medical Management
Our Medical Management system features physician directed, client specific referral and authorization processing resulting in excellent review and timely responses to the physician. We provide proactive review and management of individual inpatient and outpatient members needs. Services include:
- Referral Processing-client specific
- Onsite Concurrent Review of hospital admissions
- Post discharge follow-up calls
- Outpatient High Risk Case Management program
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Network Development and Provider Contracting
Experienced contracting professionals are available to develop a provider panel that meets the needs of each client's programs. Services include:
- Provider recruiting
- Rate negotiations and analysis
- Contract preparation and execution
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Network Management and Provider Relations
Service is our only business and our dedicated representatives work with our clients and their physicians to maintain open communications and deliver smooth operations. Services include:
- Provider education
- Office staff training sessions
- Broadcast fax communications
- Development of a client-specific Provider Manual
- Provider office visits
- Coordination of physician oversight committees
- Directory listings and system set-up
- Member assignments and transfers
- Liaison with health plans
- Proactive assessment and problem solving
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Provider Credentialing
SCPMCS offers an efficient, timely, in-house, multi-level credentialing process from initial credentialing through site visits and the recredentialing cycle. Services include:
- Credentialing/recredentialing of physicians, mid-level practitioners, ancillary providers and health delivery organizations
- Office Site Reviews
- Quality Review completed at time of recredentialing
- Recredentialing on a three-year cycle
- Delegated by health plans
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Quality Management
SCPMCS provides focused quality management and analysis using multiple methods of oversight and studies to assure compliance and continuous quality improvement. Services include:
- Annual Satisfaction Surveys-Member and Physician
- Access Surveys
- Complaints/Grievances/Appeal Review
- Continuity of Care
- Focused Quality Management Studies
- Policy and Procedures for Utilization, Quality, Case Management and Credentialing
- Provider Directories-Client Specific
- Provider Over/Under Utilization Trends
- Quality Management Oversight Committee
- Medical Claims Review and Provider Appeals
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Web Site Hosting
SCPMCS provides a web-based application for exchanging information between physicians and the MSO. Available 24 hours a day, 7 days a week, reducing faxing, voicemail, and telephone calls. Our application features strict security and encryption technology. Services include:
- Submit online authorization requests
- Inquire on authorization status
- View member authorization history
- Check eligibility
- Check status of a claim
- Submit on-line claims
- Look-up procedure codes and diagnosis codes
- Reference fee schedules and other policy information
- Print assigned member lists (Primary Care Physicians)
- Email questions to Client Services representatives
- Member accessible Physician Search
- Links to driving directions and maps to provider offices by zip code or specialty
- Member access to service information and updates
- Password-protected physician information section
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HITRUST Certified
SCPMCS has achieved HITRUST Risk-based, 2-year (r2) Certification on our EZCap suite of managed care systems. HITRUST Risk-based, 2-year (r2) Certified status demonstrates that the organization’s EZCap suite of managed care systems has met key regulations and industry-defined requirements and is appropriately managing risk.
This achievement places Southern California Physicians Managed Care Services (SCPMCS) in an elite group of organizations worldwide that have earned this certification. By including federal and state regulations, standards, and frameworks, and incorporating a risk-based approach, the HITRUST Assurance Program helps organizations address security and data protection challenges through a comprehensive and flexible framework of prescriptive and scalable security controls
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Senior Management Team
Our team of dedicated, experienced professionals supports our clients in meeting their long-range business goals while helping them manage day-to-day operations.
Joyce Cook
Chief Executive Officer
Marcia Aeschleman
Chief Financial Officer
Arlys Bartholomew
Director, Medical Management
Tristin Rausche
Director, Network Management
Scott Fowler
Director, Compliance
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