Date post: | 16-Feb-2017 |
Category: |
Healthcare |
Upload: | dell-services |
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Key Issues in Health Care Coverage
Dell Healthcare Services POV: • Payment Integrity • Utilization Management • Provider Management
2 Dell - Internal Use - Confidential
Introduction to Dell Services
52,000+ team
90+ countries
60 tech support centers
10 solution centers
Applications Services
Business Process Services
Business Consulting
IT Consulting
Infrastructure Managed Services
Cloud Services
Configuration &
Deployment
Support Services
Applications Business Process
Consulting Infrastructure Support
Strategic Alliances Acquisitions
5 global command centers
Agenda • Payment Integrity
• Utilization Management
• Provider Management
Payment Integrity
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Key challenges for the healthcare industry
Actionable recovery-oriented results stem the tide of bad behavior
Very few solutions exist with a national footprint able to apply state-specific results
Fraud schemes take hold before applicable corrections exist, costing millions of dollars
Sophisticated fraud and abuse schemes are a major problem
A less than holistic approach encourages abuse
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Typical FWA cases encountered
Mismatch between medical records and claims data
Phantom bills and charges
Exploitation of benefit plans
Billing for services never rendered or up-coding for services
Unnecessary diagnostic services or medically unnecessary services
Diagnostic code manipulation
Medical identity theft
Frequency of visits
Billing inpatient when service can be done in an outpatient setting
Unusually high HCC scores
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Address key challenges with a complete suite of payment integrity solutions
• Advanced integration of best practices and strategic partnerships provide comprehensive FWA detection and management, and facilitate improved efficiencies
• Industry-leading automated claims evaluator for complimentary claims analysis
• Cross-partner and enterprise integration and analysis is recommended to identify, validate and manage FWA
• Expert clinicians and advanced ICD-10 tools investigate and perform medical necessity and utilization reviews
• Analysis of suspicious incidents across disparate processes and systems
• Manage FWA with scores generated with advanced analytics service
• Suspect cases coming from claims and customer service queues
Investigation
Medical review
Data analytics
Revenue Management
Core Components
• Advanced analytics to improve audit & recovery results
• Implement best practices across Medicare, Medicaid, and commercial clients
• Experienced pool of RNs, coders, clinicians, pharmacists, statisticians, & data analysts
FWA Services Coordination of Benefits
Subrogation 3rd Party Recovery
UM Services Consulting & Integration
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High level lifecycle of FWA management
Claims Source from Payer (Medical & Pharmacy)
Clean Claims
Pre-payment Detection
Retrospective Detection
FWA Application
Scores for Suspected FWA Cases
Validation Services
Categorization of Reason Codes
Investigation and Recommendation
Request More Info Recommend for
Denial Recommend
Education Recommend Payment
Scoring Engine Application with HMS
Special Investigation Unit (SIU) of Payer
Feedback Loop
Dell BPO Services using the
DBPMS*
Workflow Tool
Feedback Loop
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Search for a single source for full spectrum claims integrity
Financial Accuracy Services
Clinical Accuracy Services
Complex Clinical Reviews • Place of service
• Utilization review
• Specialty audits
• Coding validation
• Clinical validation
• Medical review
Data Mining • System, policy & contract compliance
Coordination of Benefits
• Data matching and recovery
• Eligibility verification
• Identification
Fraud, Waste & Abuse
• Investigations
Subrogation
Workers’ Compensation
Premium Protection
Credit Balance
Claim Stages Pre-payment | Post-payment
Claim Types Hospital | Facility | Physician/Provider | Pharmacy | Ancillary
Error Types Eligibility | Financial | Clinical | Compliance | Fraud
LOBs Commercial | Medicare | Medicaid | Duals
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Considerations for a broad spectrum program
Pre-payment: Checks of the clinical record before a payment is made are becoming more possible and imperative
Federal edits aren’t enough: Edits and algorithms, including forensic coding customized to federal & state regulations & plan-specific policies, should be a standard expectation
Review of more esoteric services: Catches bad actors hiding in the shadows
Investigative support: Ensures quality of findings and recoveries
Under one roof: Means cohesion of communication and results
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Coordination of benefits
Data from 1,500+ insurers
Claim billed to correct party Carrier
Member Provider
Health plan
Claim and member data
Claim
Payment
Proprietary processes
Key Payer Issues:
Unnecessary Overpayments
Industry data indicates that other insurers should cover .5% to 1.5% of all paid claims
Administrative Challenges
Costly and error-prone manual processes
Multiple claim touches
Phone calls to policyholders
Extensive annual surveys
Value to be gained through improved processes
Industry data projects the potential for $0.25 per policyholder per month
For 100,000 members this would equate to $25,000 in administrative savings per month
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Subrogation
Utilization Management
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Clinical review services
• Prospective (prior
auth), concurrent
& retrospective
reviews
• DRG validation,
quality of care, bill
audits
• URAC accredited
• Quality peer
review
• External
reviews/ACA
• Third-level appeals
from insurance
departments
• URAC accredited
• Community-based
behavioral health &
waiver services
• Medical necessity,
staff qualifications,
documentation &
billing
• Onsite & desk audits
(complex)
Independent Review
Provider Audits
Utilization Management
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Clinical review process
Chart / Request Intake
• Project Specialists
• Imaging Systems
Initial Review
• Registered Nurses
• Behavioral Health Clinicians
• UR Review Platform
Initial Physician Review
• Staff Physicians (IM, GP, FP, Surgeon)
• Contracted Physician Reviewers
Reconsideration w/2nd Level Physician
• Specialty Matched Physician
• Physician-to-Physician Consult
Appeal
• Medical Director
• Clinical Director
• Legal
Care Guidelines
Providing much more than authorization criteria, the evidence-based clinical guidelines which are used drive high-quality care through tools such as care pathway tables, flagged quality measures and integrated medical evidence
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Utilization management overview
Offer flexibility to customize group-specific business rules
Experienced staff: • UM nurses must have active licensure in state
of practice; diverse medical backgrounds; at least 5 years of clinical experience
• Review to see if nurses have 4-year degrees, prior call center experience, and/or medical coding/terminology knowledge
Urgent call center is available around-the-clock for weekend and emergency pre-certifications and appeals
Standard UM call center is open 8:00 am–8:00 pm ET, Monday–Friday
Automated system triggers identify members who may benefit from case management intervention; supports quality of care & cost containment
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New to market: Healthcare Information Security Program Auditor
Referral Sources
Automated triggers are built to identify UM cases that will benefit from Case Management
By identifying high-risk cases through precertification, can
begin to actively manage members earlier, which greatly
increases the opportunity for cost savings
Allows for early intervention that
supports quality of care and cost containment
Examples of cases to be referred from can UM include: • High-cost, high-acuity ICD-9 diagnosis
codes and CPT codes
• Hospital length of stay of five days or more
• Previous CM activity/referrals
• Two or more events in previous 180 days
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Utilization management process flow
Toll-free call is received from the provider or member for precertification. Call is screened and patient information is obtained by Intake Coordinator.
Medical necessity criteria is met: Services/admission certified, length of stay assigned, authorization letters sent within 1
business day.
Medical necessity criteria is not met: Case sent to physician for medical necessity determination.
Physician determines medical necessity.
Approved: Length of stay assigned, requestor notified
within one business day, authorization letters sent.
Not Approved: Noncertification letters sent, provider and attending MD
notified and informed of appeal rights.
Criteria is applied. Medical necessity determination is made.
Plan of care and reason for admission obtained. If the information is incomplete, Calls made to provider to obtain additional information.
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Utilization management benefits
Cultural & Operational Fit
• Vendor should have a strong cultural understanding of its customer’s operating environment
Engagement Model • BPO engagement model
provides flexibility at lower costs
• Managed engagement model ensures outcome-based relationship
Leadership in UM Services
• Does it have leadership in UM services, with experience in state, federal, and health plan-specific requirements?
Accreditation • Must have URAC accreditation
for UM and independent review services
Lower Startup Costs
• Vendor should invest in setting up and training a team on health plan-specific processes
Flexible Capacity
• Vendor should offer flexible options to ramp-up/ ramp-down that can help health plans manage inventory during peaks and valleys of membership growth
Continuous Process Improvement
• Does it have time and logistical experience in developing and using BPO=-specific tools to optimize processes for continuous improvement?
Cost Containment Analytics
• Does it provide, at a minimum, quarterly statistical reporting of PA/UM results with cost containment recommendations?
Provider Management
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Simplified view of provider management flow
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Provider Contract Data
Contract Data Uses:
• Credentialing • Directories • Reporting • Claims
adjudication • Provider
payments
Contract Data Includes:
• Demographics • Fee schedules • Discounts &
payment exceptions
• Provider groups • Other contract-
based information
Aligning fee schedules with providers and provider types
Inputting provider contract data into health plan’s database for downstream uses
Inputting provider demographic updates
Alignment with health plan’s credentialing department
Adding/deleting providers w/groups and affiliations
Doesn’t include:
• Provider outreach for contracting or updated information/demographics
• Review contract for accuracy/corrections
• Provider follow-up
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Using a NCQA end-to-end credentialing organization
*Primary source verification
Easy to use for input & mgmt. of provider data & support docs
Smart Web Portal
Multiple Users & Customers
• Hospitals
• Commercial health plans
• CAQH
• State Medicaid Agencies
• MA health plans
• Other licensure orgs.
CVO Internal
Engine
• Application packet
• State licensure
• CDS
• DEA
• OIG
• Board cert.
• Background check
• Many Others
Application printed, mailed, collected, scanned, w/3x follow-up
Mail & Collect
Electronically retrieve applications directly from CAQH’s ProView
CAQH
Multiple input sources to cover all bases and options; greater flexibility; highly customizable
Inputs
Performance guarantees; costs reduced by 20-40%; speed verifications by 30-60%
PSV* resources
Screen providers for cred/recred & demographic changes; fed & state sanctions; maintain nat’l certs.
Monitoring
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Why must you have single source of truth for provider data?
Includes which providers are accepting new patients, locations, contact information, specialty, medical group, & any institutional affiliation; directories must be easily accessible to plan enrollees, prospective enrollees, the State, FFM, state exchanges, HHS, & OPM
*paraphrased from 45 C.F.R. 156.230(b)
2.4% of all providers change addresses or other contact information every month
5% change their license status every year
30% change their hospital or practice-group affiliations every year
20% of claims fall out of auto-adjudication due to provider data issues; adds ~$8-15 per affected claim
35% of provider listings contain errors; 32% of listings are duplicates; false provider information is billing fraud
Paying sanctioned providers triggers CMS fines; incorrect 1099’s triggers IRS fines;
Up-to-date: at least monthly & easily accessible when general public is able to view all current providers for a plan in the directory on the issuer’s website through a clearly identifiable link/tab without having to create/access an account or enter a policy number
The public should be able to easily discern (1) which providers participate in which plans & provider networks, & (2) if the issuer maintains multiple provider networks, to see the plans & networks associated with each provider, including the tier in which the provider is included*
Effective 1/1/16, exchange & Medicare Advantage plans: Must publish an up-to-date, accurate, & complete provider directory
≤$25,000 per beneficiary for Medicare Advantage; ≤$100 per beneficiary for FFM
Thank you
For more information:
Visit Dell.com/HealthPlans
David M. Buchanan, JD | 601-259-7579 | [email protected]
Jody Miller | 913-901-7290 | [email protected]