Managed Care
Health Solutions


Managed Care Solutions

We specialize in assisting Manage Care Organizations, HMO’s, IPA’s, PPO’s,PFFS etc to enable them to offer high quality of care at contained costlevels. Organizations require the agility to quickly respond to market demands,regulatory changes and new customer requirements. Guhilot provides managed care organizations (MCOs) with real competitive advantage by simplifying processes, improving productivity and providing the data to shape management decisions, leading to a financially successful organization.

We have been in the managed care business since 2005 ensuring that all our customers remain at the forefront of frequent changes as they happen.The move to value-based care and widespread variability in care means quality measurements now play an integral role in strategic health care planning. Industry stakeholders need reliable provider quality information to guide decisions around new payment and delivery models, plan performance and tiering, network management, provider reimbursement,risk management, and contract negotiation. In order to achieve our customers goals, we use advanced healthcare information tools and systems driven by both human and automated healthcare business processes to deliver integrated solutions focused on quality. We provide secure and compliant data acquisition, processing, and management by following industry standards and formats.Our decades of expertise in the managed care business ensures that our provider networks stay focused on effective patient care while we manage work in the background help navigate the compliance and service delivery objectives.

Our Managed Health Care Service Expertise

IPAs must appropriately utilize services necessary for their members.Over utilization and underutilization can both drive up costsunnecessarily. Our expert team of professionals can help you tonavigate this maze with relative ease ensuring thatyou meet yourutilization goals at all times.
We have experience handing HCFA1500/UB92 claims forms submitted in as hard copy or Electronically or via Web Portal.Our claims department provides efficient and prompt claims processing services for contracted IPA’s, Managed Hospitals and provides claims adjudication in contract agreements. We are able to customize IPA payments based on Health Plan contracts, provider contracts, as well as member eligibility and member benefits.Our state-of-the-art RPA based claim system is able to log, adjudicate and pay claims automatically based on defined rules. Our claims system automates most of the processing to allow greater accuracy and faster claim turnaround time.

With value-based payments coming into prominence, completion of IPAquality metrics as established CMS requirement is paramount torealizing benefit from shared savings. It is important for the IPA tounderstand how they are performing on each individual metric toensure a high compliance rate by the end of the year.We assist you to identify:

  • Physician customized patient care priorities
  • Members missing required preventative procedures
  • New assigned members that need AWV
  • Which intervention strategies appropriate
We provide and coordinate care management where they can have the greatest impact. Powered by advanced analytics predictive technology,we identify which patients are most likely to experience serious and preventable medical episodes. Our dedicated care advisors draw on their clinical backgrounds and our proven methodologies to optimize patient outcomes.
Provider Contracting is very important to ensure IPA compliance. Hiring incompetent healthcare providers or allowing them to remain with your facility can lead to increased liabilities in malpractice suits. In order to ensure that your facility does not suffer from this, it is important that credentialing and enrolment of your providers is managed properly and kept up to date.
It is extremely important to ensure weekly member eligibility update to avoid services being rendered to non-eligible members. Thereby avoiding financial losses to the IPA.Our teams have experience dealing with over 50 different insurances across US to ensure most up-to-date member information for our physicians, claims, and utilization management department.
One of most overlooked requirements in Medicaid programs is timely and effective encounter submissions. The process gets more complicated with inconsistent file formats, submission rules, SLA and associated penalties.We offer end-to-end encounter submission and reconciliation processes that can be used to streamline operations, leveraging most popular formats and rules. Our scalable, workflow-based solution improves encounter accuracy, completeness and timeliness, reduces administrative costs, enables health plans to reduce state-levied penalties and to adjust to state- based changes quickly.
We have years of experience providing high quality, cost-effective technology solutions, and business process re-engineering services across various platforms. We provide 24×7 customer support to manage your IT infrastructure and remove this burden from you and allow you to concentrate on other critical business practices.You can choose from one of the various solutions we provide or use our software development and engineering skills to customise your existing managed care solutions.

Our Managed Care Service Advantages

Healthcare organizations over the last few years have struggled with management’s consent to become more well-organized and profitable.Healthcare organizations are becoming more and more aware that it’s strategically imperative to hire a service partner in a progressively stiff and competitive business field. By hiring a service partner for non-core operations, they can focus on strategic issues of growing their network.Our services are geared to offer comprehensive, integrate and automate solutions that that enable high performance and quick response at all times.

Broader experience

Guhilot administers more than million lives currently and has worked with over 100 different payers since 2005.

Greater expertise

Guhilot employs certified professionals in al lour product lines. We have a collective team experience of over200-man years.

Up-to-date knowledge base

As a result of working with payers andproviders every day, the knowledge of the team handling yourcontracts remains current.

Flexible Engagement Models

We are flexible in scaling up or down based on your business needs. Even our contracts can be terminated at any time simply by giving us sixty days written notice.

Contained Operating cost

Your cost will be less than that of employing individuals with comparable experience, and our flat monthly professional fee means no surprises and easier, more accurate budgeting.

Onsite and Offsite teams

You enjoy complete control over team members working for you. We have regular onsite visit by team members and regular video conferencing meeting for smooth coordination.

How You Benefit with Our MCOs

Reduced administration costs by 40-60%

We have systems,processes and trained professionals to contain your cost with in 3 months of engagement.

Lower medical costs by 30%

Guhilot employs certified professionals in al lour product lines. We have a collective team experience of over200-man years.

Optimal internal resource use

With our team to ease thepressure of daily tasks, you can focuse your internal resources onthe higher value-add member and provider interactions.

Improved Star/Quality Ratings

We have dedicated Healthcare Quality measures/NCQA/Quality managers to ensure you successfully navigate and execute all compliance reporting needs on timely basis.

Cutting Edge Informatics

We put lot of importance in automating systems and databases using latest AI/RPA technologies to give you information and insights for making quick informed decisions.

Service expansion

Supporting the improvement of healthoutcomes and opening up the possibility of generation of newrevenue streams through new program offerings.


Positioning for growth in new markets by tapping into an expansive and highly-skilled workforce.

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