The Compliance Advantage in Medicare Advantage A journey from the brink to the fore front
Jeremy Dressen, Vice President, Medicare Operations
•
Medicare Advantage
Commercial
• Founded in 2007
• Serving over 23,000 MA members
• 9% market share of Seattle/Tacoma
• RiverLink Health & HeartlandPlains Health founded in 2015
• QCA founded in 2016
• Serving over 4300 combined members
• Founded in 1994 • Serving over 137,000 members • Products Include:
• Employer Sponsored • Exchange • Individual • ASO • Med Sup
69% MA member growth since CHI acquisition
Catholic Health Initiatives
• Founded in 1996
• One of the nation’s largest non-profit hospital systems, CHI operates in 17 states & comprises over 100 hospitals, 11 clinically-integrated networks, and a diverse network of facilities/services that span the care continuum.
• More than $15.9B in revenue and $1.1 billion in financial assistance FY2016
90% Commercial member growth since CHI acquisition
Why focus on Appeals & Grievances?
• High Risk: CMS Program Audit
• High Reward: Medicare Star Ratings
U.S. Government suspends enrollment in Cigna Medicare Advantage, drug plans. - Reuters Health News, Jan 22, 2016
“The U.S. government has suspended new enrollment in
Cigna Corp’s Medicare Advantage health insurance and
prescription drug plans, saying Cigna had ‘widespread and
systemic failures’ that prevented patients from accessing
medical services.
The government said Cigna did not handle complaints and
grievances properly from patients who had been denied
coverage for health benefits or drugs…These deficiencies
posed ‘a serious threat to the health and safety of Medicare
beneficiaries’ and followed years of noncompliance.’”
http://www.reuters.com/article/us-cigna-medicare/u-s-government-suspends-
enrollment-in-cigna-medicare-advantage-drug-plans-idUSKCN0V01LV
Our Business Imperative
2014 – Measurement Year 2015 – Reporting Year 2016 – Year 2017 – Bonus Year
Medicare S TAR Performance
S oundPath HealthWt.
MY 2014
Actual
Appeals Auto–Forward 1.5 1
Appeals Upheld 1.5 1
Plan Makes Timely Decisions about Appeals 1.5 2
Reviewing Appeals Decisions 1.5 3
Complaints about the Health Plan 1.5 4
Members Choosing to Leave the Plan 1.5 4
Beneficiary Access and Performance Problems 1.5 3
CAHPS Customer S ervice 1.5 3
Improv. Health Plan Quality Improvement 5 1
IRE
CMS
Member Quicker response time and case completions
Case status information readily available
Provider Quicker response time and case completions
Case status information readily available
Simplified experience
Staff Organized workflows and queues
No manual tracking
Seamless letter generation
Quick access to necessary documentation
Leadership Consolidated view of case status and SLA performance
Accurate, timely CMS reporting and audit readiness
Workload management
Stable, reliable environment
Initial Goals for A&G / Pega
Agile Development Approach
• Project team formed; strong collaboration among SMEs, IT, vendors
• Executive level ownership and oversight
• Well laid plans; but commitment to flexibility
• Ticketing system, scrums utilized to support Agile development process
• 27 product releases since Sept. 2015
• Model office approach for future projects
Your Logo Here
QualChoice Health IT – Support and Development
QualChoice Health Automated Workflow
VPN – Secure Connection
Pega Cloud
Pega Healthcare
Industry Foundation
QualChoice Health
Trizetto QNXT Claims Management – Member lookup
Fax Server - Authorizations
Microsoft Exchange Email
Active Directory – User Authentication
Pega Cloud Operations
Appeals & Grievances Application
Utilization Management
Tracker Application
Pega Product Technical Support
Support and Agile Development Partner - Capgemini
QualChoice/Pega Logical Architecture
Multiple avenues for intake; 19 Searchable / Reportable Fields
Level of Appeal
Case ID
Case Type
Claim ID
Authorization Number
Member ID
Member Name
Provider Type
Provider ID
Provider Name
Ancillary Name
Facility Name
Received Date/Range
Case ID (hyperlink)
Level of Appeal
Health Plan Name
Type of Appeal/Grievance
Priority
Status
End users include:
• A&G Staff
• Customer Service
• Nurse Care Managers
• Pharmacists
• Administrative Staff
• Sales
• Claims
• Medical Directors
Intuitive Layout for Diverse Staff Needs
Complex Business Rules Made Simple
Real Time Work Baskets, Status and Dashboard
Integrated Case Documentation & Letter Generation
Practically Magic Reporting
RESULTS
Successfully addressed all CMS compliance areas
Real-time information for members, providers on case status
Reporting cycle time down >50%
FTE costs reduced by >33%
Improvements in employee retention, morale
Agile process - Pega successfully deployed to prior authorization
Major STARs improvements
Results
*Based on CMS Plan Preview Data
**Based on internal QualChoice monitoring and trending against published CMS cut-points
***N=13; N/A at <10
Medicare S TAR Performance
S oundPath HealthWt.
MY 2014
Actual
MY 2015
Actual
MY 2016
Actual*
MY 2017
Forecast**
Appeals Auto–Forward 1.5 1 5 5 5
Appeals Upheld 1.5 1 N/A 2*** 5 or N/A
Plan Makes Timely Decisions about Appeals 1.5 2 3 4 5
Reviewing Appeals Decisions 1.5 3 3 5 5
Complaints about the Health Plan 1.5 4 5 5 5
Members Choosing to Leave the Plan 1.5 4 5 3 5
Beneficiary Access and Performance Problems 1.5 3 2 5 S unset
CAHPS Customer S ervice 1.5 3 3 4 4
Improv. Health Plan Quality Improvement 5 1 3 5 TBD
IRE
CMS
Closing Thoughts
• Don’t forget the human equation
• [Thought] process reengineering critical to maximizing PEGA capability
• Agile development allows rapid iteration & continuous process improvement with end users
• Test, test, test
• And most importantly…