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Health Care


Cambria’s Health Care practice has been at the forefront of health care reform across the United States. The Affordable Care Act has been transformative for both public- and private-sector organizations, presenting many opportunities and challenges. Our focus has been on programs such as Medicaid, state insurance exchanges, mental health, and health information exchanges. Our services range from planning and analysis through the entire systems development life cycle (SDLC) to ongoing maintenance and operations.

Whether it is managing complex health claims and enrollment operations or developing performance metrics for a mental health program, our human approach to service delivery makes the often difficult challenges manageable and the results predictable. We believe that people—yours and ours—make the difference, and our achievement relies on the collaborative efforts of both to deliver business success.

Insurance Exchanges

Cambria has extensive experience working with states on the planning and implementation of state-based Exchanges, including in California, New Mexico, Mississippi, and Washington. This experience has resulted in a deep functional and technical understanding of state-based Exchanges, as well as the Patient Protection and Affordable Care Act (PPACA).

Cambria service offerings for state-based Exchanges include requirements development, systems design and development, implementation, and operations planning and support.


The Health Information Technology for Economic and Clinical Health Act (HITECH Act), funded by the American Recovery and Reinvestment Act of 2009, is the foundation of the Affordable Care Act (ACA) of 2010. Cambria has participated in state health and human services efforts to improve the quality, safety, and efficient application and use of adopted health IT standards, including both privacy and security provisions.

Cambria staff has also provided environmental assessments, recommendations, testing, and implementation in support of the meaningful use of electronic health records (EHR), in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.


Cambria’s health care consultants are helping state and local governments interact more effectively with the Centers for Medicare & Medicaid Services (CMS) to better meet the needs of families and children they serve. In addition, they are helping these organizations navigate the changes in the Medicare and Medicaid areas affected by health care reform.

Cambria staff has provided consulting services in the areas of claims management, maintenance, operations support, and development to promote state Medicaid programs.

Health Plans and Payers

The Affordable Care Act is driving health insurance delivery and payment reforms and effecting changes to health plans and payers. With the anticipated surge in dual eligibles, the creation of Accountable Care Organizations (ACO), and the regulatory reporting requirements, plans and payers will be challenged to meet these needs.

These changes will also affect health care providers and, ultimately, consumers of health insurance. Cambria is at the forefront of working with state health insurance exchanges and their private sector partners to meet the growing needs generated by the Affordable Care Act.

Case Studies

As part of the 2010 Patient Protection and Affordable Care Act, states were given the option to create a federally-funded state health insurance marketplace. The contracted system integrator’s build activities required program and technical subject matter expertise to guide requirements definition, design, testing, and implementation. The Washington Health Benefit Exchange further intended to establish key operational components such as customer service, eligibility, and plan management functions.

Cambria guided the system requirements, design, testing, and implementation activities for core functions such as eligibility, Small Business Health Options Program (SHOP), plan management, and enrollment. The Cambria team provided business process, technical, and coordination support for Exchange IT integration efforts with the carriers in the areas of plan management, enrollment, and financial management. In addition, Cambria facilitated the development of future business processes and supported business process documentation development for eligibility, administration, enrollment, and SHOP.

Cambria completed version 1 of the design and development of the Washington Health Benefit Exchange systems for both the individual and SHOP plans, including integration and user acceptance testing. The Exchange successfully launched the Washington Healthplanfinder on October 1, 2013. Washington’s Health Benefit Exchange will extend health coverage for up to a million previously uninsured residents through Medicaid and subsidized insurance. Currently, Cambria is providing ongoing operational and program support.

California was the first state to create a health benefit exchange, Covered California, following the passage of the 2010 Patient Protection and Affordable Care Act. Charged with creating a new insurance marketplace, Covered California required assistance in infrastructure, policy and technology planning, and development for a successful launch of the Exchange.

Cambria was actively involved in the initial planning efforts for the California Exchange, leading and supporting the project management and technical architecture efforts in preparation for the Exchange system integrator vendor procurement. These project management services included vendor oversight, management of CCIIO/CMS phase gate reviews, and facilitation of the information architecture planning discussions with key state interface partners. Cambria was also engaged to oversee and manage the end-to-end procurement of the Small Business Health Option Program (SHOP) vendor for Covered California.

Cambria’s efforts helped Covered California finalize the overall Exchange technical requirements for inclusion in the systems integrator RFP. For the SHOP Exchange, Cambria helped Covered California select and finalize the contract for the SHOP administrative services vendor.

In 2012, the Mississippi Division of Medicaid was informed that its current electronic medical record (EMR) vendor would no longer support the Medicaid Electronic Health Records System (MEHRS) and ePrescribing System (eScript) solution to allow providers to meet the criteria of Stage 1 Meaningful Use. Therefore, the Division of Medicaid sought to upgrade its current system to an Office of National Coordinator-certified EHR systems on a tight timeline.

Cambria was engaged to provide leadership through the testing and implementation phase of the upgraded product. In addition, Cambria provided review and analysis during the design, development, and implementation phase; validated requirements through the development lifecycle; and assisted in acceptance of the documentation.

The outcome of Cambria’s partnership with the Division of Medicaid was a successful go-live of Phase 1 of the EHR system within a strict timeline—for hundreds of users and providers in the State of Mississippi. Phase 2 of the implementation went live in January 2014.

Cal eConnect, a non-profit public benefit corporation (public-private partnership) designated to act as the governing body for California’s health information exchange (HIE), commissioned a laboratory assessment study. A key business challenge was to identify practical strategies for supporting EHR Meaningful Use by accelerating the implementation of a standard for labs within California’s diverse and fragmented landscape.

The study, led by Cambria, involved the assessment of the environmental landscape, market, and individual readiness of California’s medical laboratories to adopt the HL7-compliant messaging standard for reporting lab results from an electronic laboratory results (ELR) system or lab information system (LIS) to an ambulatory EHR. Cambria’s team gathered existing survey data, interviewed laboratory staff (from hospitals, physician offices, and independent labs) and HIE organizations from other states that have implemented a lab messaging standard, and collected other data to analyze the current state of lab interoperability readiness.

The initial survey and planning work was completed. Cambria developed recommendations to identify practical strategies to support EHR Meaningful Use by accelerating the implementation of the HL7 messaging standard for reporting lab results from an ELR or LIS system. Cal eConnect, California Department of Public Health (CDPH), California Department of Health Care Services (DHCS), and its business partners will leverage this messaging standard.

California’s Medi-Cal and the federal Medicare programs are partnering to launch a three-year demonstration, starting in June 2013, to promote coordinated health care delivery for beneficiaries who are dually eligible for both Medicare and Medi-Cal—called dual eligible beneficiaries.

Cambria was engaged to provide support for system development and operations services necessary to successfully implement the Duals Encounter Data Capture and Transmission System (EDCTS) project. As the provider of maintenance and operations support for the Short Doyle Medi-Cal 5010 system, Cambria will leverage key artifacts from that system to accelerate implementation of the solution.

Cambria’s team is currently developing the system for the project. Cambria’s efforts include analysis, design, development, implementation, training, testing, and support and monitoring. The goal of this effort is to promote coordinated health care delivery for beneficiaries who are dually eligible for both Medicare and Medi-Cal.

The Mississippi Division of Medicaid is currently engaged with its Fiscal Agent to modernize its current eligibility and enrollment system (MEDS and MEDSX). The vision is to provide one unified Medicaid and Children’s Health Insurance Program (CHIP) eligibility determination system that is compliant with the ACA, including Modified Adjusted Gross Income (MAGI) rules, interoperability, interaction with the Federal Data Services Hub, Seven Conditions and Standards, and the Medicaid Information Technology Architecture (MITA) Maturity model.

Late in the project schedule, Cambria took over the task of providing independent verification and validation (IV&V) services for the software development lifecycle. Cambria is validating that the modernized eligibility system meets Centers for Medicare and Medicaid Services (CMS) certification criteria and is in alignment with Mississippi’s goals and objectives.

To date, Cambria has provided key recommendations regarding timeline, feasibility, and scope that have been adopted by the Mississippi Division of Medicaid. This engagement is ongoing and is scheduled to be completed in June 2014.

The client reinstalled a product by TriZetto called QNXT. Trizetto was engaged to conduct a fit-gap assessment of the software and processes to determine what functionality could be leveraged for greater optimization. The assessment uncovered a multitude of areas in the system that were not leveraged for process efficiencies. TriZetto assisted with the technical assessment, but the client needed an experienced project manager and team to work as its advocate in overseeing the implementation of the software and the process improvements that resulted from this change initiative.

Cambria partnered with Linea Solutions to provide project management, business analysis, research, project advisory, quality assurance and training services to help oversee the successful implementation of QNXT. Cambria provided the procurement support in identifying, selecting and negotiating a system implementer as well project manager and quality assurance services on the project.

Cambria helped mitigate major risks by recommending the replacement of the original system implementer and negotiating a favorable contract for the client. Additionally Cambria provided training giving the client best practices, repeatable processes and standard project management tools and templates to improve its operations and overall success.

Self-funded health plans must choose between using an insurance carrier’s services, which offer big discounts but provide little data on the providers and services driving costs, or using a leased network, which may offer more data on spending but smaller discounts. In both cases, plans are subject to significant and seemingly arbitrary rate increases from the carriers. The challenge is providing strong discounts and the necessary data to make informed decisions about cost control.

Cambria’s Custom Provider Network team is solving this challenge by building custom networks of providers for the exclusive use of the contracting plan; typically, using Medicare-based pricing that provides strong discounts and limits future cost increases. More importantly, our Custom Provider Network team analyzes the plan’s costs on a monthly basis and provides consultation on how changes in the plan may reduce significant cost drivers. Finally, stop-loss carriers favor our approach and offer their best discounts to plans using our Custom Provider Network.

Our Custom Provider Network team builds networks for self-funded plans that result in significant savings compared to the traditional leased network. The data analysis and consultation allows plans to make small changes that have big financial impacts, while keeping members happy. Plans using Custom Provider Networks have more visibility on their health care costs and more control over where and how the plan’s money is spent.