Key Issues in Healthcare Coverage

Key Issues in Health Care Coverage

Dell Healthcare Services POV: • Payment Integrity • Utilization Management • Provider Management

2 Dell - Internal Use - Confidential

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http://www.ikasystems.com/Home.aspx

Agenda • Payment Integrity

• Utilization Management

• Provider Management

Payment Integrity


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


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


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


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


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


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


Subrogation

Utilization Management


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


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


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


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


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.


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


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


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


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]

Key Issues in Healthcare Coverage

Healthcare

Transcript of Key Issues in Healthcare Coverage