Key  Revenue  Management  Ini0a0ves  with  Increasingly  Scarce  Resources  

March  18,  2014  

Overview  

!   Complexity  of  Revenue  Management  !   Key  Revenue  Management  Ini0a0ves  !   Revenue  Management  Strategies  !   Resources  Needed  for  the  Ini0a0ves  !  Using  Health  Plan  Resources  versus  Vendors  !   Reason  for  Scarce  Resources  !   Impact  of  Scarce  Resources  !   Recommenda0ons  for  Success  

Complexity  of  Revenue  Management  

!  Mul0ple  disciplines  are  involved      

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Complexity  of  Revenue  Management  

!  Mul0ple  disciplines  are  involved      

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Complexity  of  Revenue  Management  

!  Mul0ple  disciplines  are  involved      

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Complexity  of  Revenue  Management  

!  Mul0ple  disciplines  are  involved      

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Complexity  of  Revenue  Management  

!  Need  coordina0on  across  disciplines:  ! Success  depends  on  effec9veness  across  the  enterprise  ! Skilled  resources  needed  in  each  area  ! Only  as  successful  as  your  weakest  link  ! Compe9ng  plan  demands  for  each  area’s  9me  and  resources  

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Key  Revenue  Management  Ini0a0ves  

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Key  Revenue  Management  Ini0a0ves  

!   Encounters  Submission  ! Collec9ng,  FormaIng,  and  SubmiIng  the  Data  ! Correc9on  of  Errors  based  on  Response  Files  

!  Maintaining  Source  Data    ! Member  Eligibility,  Claims,  and  Provider  Data    

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Revenue  Management  Strategies  

!   Clinical  Review  of  Risk  Score  Gaps  ! Focus  on  chronic  condi9ons  and  filter  out  acute  ! Determine  probability  member  has  chronic  condi9on    

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Revenue  Management  Strategies  

!   Iden0fy  Sources  of  Nega0ve  Revenue  Impact  ! Determine  nega9ve  revenue  impact  by  provider  groups  ! Compare  provider  submission  stats  and  documenta9on  quality  

 

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Revenue  Management  Strategies  

!  Mine  Results  for  Refining  the  Targe0ng  Algorithm  ! Determine  Provider  ROI  ! Determine  Provider  HCC  Persistency    

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Revenue  Management  Strategies  

!   Predic0ve  Analy0cs  ! Use  of  pharmacy  and  other  supplemental  sources  ! Iden9fy  suspect  condi9ons  that  have  never  been  reported  

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Resources  Needed  for  The  Ini0a0ves  

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Using  Health  Plan  Resources  versus  Vendors  

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Health  Plan   Vendor  

Reason  for  Scarce  Resources  

!   Con0nually  changing  government  regula0ons  ! Changes  are  assured  to  occur  every  year  ! Some9mes  change  is  dras9c  with  a  very  short  9me  frame  

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Reason  for  Scarce  Resources  

!   High  Degree  of  Complexity  ! Need  skilled  resources  with  experience  in  many  areas  ! Data-­‐driven  analy9cs,  and  technology  intensive  work  ! Most  plan  resources  wear  mul9ple  hats  and  are  spread  thin  

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Reason  for  Scarce  Resources  

!  Managed  Care  Plan  Challenges  ! Must  excel  in  core  competencies  to  provide  member  care  ! S9ll  need  staff  to  support  func9ons  all  companies  have:  accoun9ng,  sales,  marke9ng,  finance,  customer  service,  etc.  

! Mul9ple  Lines  of  Business  with  very  different  regula9ons  

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Examples  of  Changing  Government  Regula0ons  

!   CMS  Medicare  Payment  Year  2015  Advanced  No0ce  ! Con9nua9on  of  the  blended  payment  year  model  ! Introduc9on  of  an  ICD-­‐10  crosswalk  post  October  1  ! Home  health  assessments  need  subsequent  provider  visit  ! 3  Star  underperforming  plans  may  be  terminated  

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Examples  of  Changing  Government  Regula0ons  

!   HHS  Commercial  Benefit  Year  2014  ! Healthcare.gov  technical  issues  delayed  enrollment  ! REGTAP  delays  and  Edge  Server  uncertainty  clouds  9meline  ! Funds  transfer  formula  outcome  difficult  to  predict  in  advance  

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Impact  of  Scarce  Resources  

!   Con0nuous  string  of  projects  due  to  rapid  change  ! High  degree  of  subject  maaer  exper9se  needed  to  keep  up  ! Huge  industry  wide  impacts  such  as  HIPAA  and  ICD10  

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Impact  of  Scarce  Resources  

!   Complexity  of  Projects  Makes  Everything  Go  Slower  ! Lack  of  skilled  and  experienced  SME’s  are  a  limi9ng  factor  ! Many  discussions  needed  at  a  very  detailed  level  ! Lack  of  availability  of  SME’s  in  any  area  hinders  whole  project  

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Impact  of  Scarce  Resources  

!  Managed  Care  Plan  Never  Ending  Challenges  ! Work  volume  and  rate  of  change  means  resource  overload  ! Resources  stretched  thin  across  departments  and  LOBs.  ! Turnover  of  any  key  resources  has  a  drama9c  impact  

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Recommenda0ons  for  Success  

!   Know  the  Strengths  and  Skills  of  Your  Resources  ! Aligning  tasks  based  on  strengths  drives  efficiency  ! Knowing  strengths  also  determines  areas  of  weakness  

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Recommenda0ons  for  Success  

!   Consider  Vendors  Based  on  Plan’s  Resource  Gaps  ! Leverage  internal  resources  where  possible  and  cost  effec9ve  ! Recognize  gaps  in  skills,  experience,  resources,  or  capabili9es  ! Look  for  value,  reputa9on,  and  right-­‐sized  solu9ons  

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Recommenda0ons  for  Success  

!   Re-­‐Evaluate  Revenue  Management  Every  Year  ! Nothing  is  the  same  year  to  year  and  revenue  management  should  not  be  the  same  either  

! Every  year  brings  different  challenges  in  different  areas  ! New  and  exis9ng  vendors  change  capabili9es  every  year,  so  choose  wisely  

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