WV HFMA Conference Tuesday October 21, 2014 Flatwoods, WV.
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Transcript of WV HFMA Conference Tuesday October 21, 2014 Flatwoods, WV.
WV HFMA ConferenceTuesday October 21, 2014
Flatwoods, WV
Meeting Agenda
Introductions
Brief History
Available Products
Department Specialties
Questions and Answers
Health Plan Introductions
Introductions Brad Minton
VP Network Services304-598-3911
Karen Lavery Provider Relations-Education Coordinator304-598-3911
The Health PlanHistory
The Health Plan History A 501c-4 not-for-profit corporation,
chartered in West Virginia and domiciled in Ohio (St. Clairsville) in 1979
One of the largest locally managed MCOs in Ohio and West Virginia, serving over 350,000 covered lives
Established and financially secure with over $200 million in reserves
Commercial service area encompasses 76 counties in Ohio and West Virginia
The Health Plan History Regional Expansion 2014 / 2015
17 Counties in SE Ohio, Virginia and Northern Kentucky
National Expansion 2015 Acquiring Licenses in all 50 States
Focus on TPA Services and Government Programs
Regional Partnerships
Mergers and Acquisitions
Available Products
Health Plan Lines of Business Fully Insured Plans (HMO, EPO, POS, PPO), ACA Metal
Plans
Self Funded Plans (HMO, EPO, POS, PPO, THP RE)
Managed Workers’ Compensation Program (Ohio MCO), TPA, Managed Disability, FMLA Administration
PBM Management Capabilities
Vision and Dental Programs
Medicare Products (MAPD, DSNP, Medicare Supplement)
WV Medicaid – Mountain Health Trust
WV PEIA
Membership Breakdown
34,330
25,432
15,825
52,230
Commercial
MedicareAdvantage
Medicaid
Self Funded
Medical Membership by Line of Business
UPSHUR
LEWIS
RANDOLPH
BARBOUR
PLEASANTS
WYOMING
RALEIGH
WOOD RITCHIE
WIRT
WAYNE
BRAXTON
HARRISON
SUMMERSMONROE
MERCER
ROANE
KANAWHA
CLAYPUTNAM
CABELL
PRESTON
WEBSTER
POCAHONTASNICHOLAS
DODDRIDGE
TYLER
MONONGALIAWETZEL
MARSHALL
MINGOLOGAN
MCDOWELL
MASON
JACKSON
LINCOLN
BOONE
GILMER
FAYETTE
GREENBRIER
CALHOUN
BERKELEYMORGAN
JEFFERSON
HANCOCK
OHIO
BROOKE
PENDLETON
TUCKER
HARDY
GRANT
MINERALHAMPSHIRETAYLOR
MARION
Current Service Area
Approved By CMS Enrollment 8-1-14
Application August 2014
OHIO
PENNSYLVANIA
MARYLAND
VIRGINIA
KENTUCKY
HEALTH PLAN Medicaid Service Area August 2014
UPSHUR
LEWIS
RANDOLPH
BARBOUR
PLEASANTS
WYOMING
RALEIGH
WOOD RITCHIE
WIRT
WAYNE
BRAXTON
HARRISON
SUMMERSMONROE
MERCER
ROANE
KANAWHA
CLAYPUTNAM
CABELL
PRESTON
WEBSTER
POCAHONTASNICHOLAS
DODDRIDGE
TYLER
MONONGALIAWETZEL
MARSHALL
MINGOLOGAN
MCDOWELL
MASON
JACKSON
LINCOLN
BOONE
GILMER
FAYETTE
GREENBRIER
CALHOUN
BERKELEYMORGAN
JEFFERSON
HANCOCK
OHIO
BROOKE
PENDLETON
TUCKER
HARDY
GRANT
MINERALHAMPSHIRETAYLOR
MARION
Service Area Prior to ExpansionExpansion 2012Expansion 2014
Expansion 2015
OHIO
PENNSYLVANIA
MARYLAND
VIRGINIA
KENTUCKY
HEALTH PLAN MEDICARE SERVICE AREA
August 2014
Third Party Administration
Services
Customer service, CSF forms
Claims processing and claims payment
Medical management and utilization review
Disease management
Bank reconciliation services
HIPAA certification administration
Proprietary systems
SPD development
COB, subrogation, and fraud investigation
Third Party Administration (TPA) Services
Enrollment meetings and ID cards
Staff medical directors
Staff pharmacists
Staff social worker
Month end report package
Additional services include: stop-loss insurance and COBRA administration
Third Party Administration (TPA) Services
Claims
Claims processed for physicians, facilities, and dental
Strategic partnership with pharmacy and vision vendors allowing claims information to be loaded in our system in a timely manner
6 certified coders, 13 registered nurses, and 32 clinical technicians review claims
Electronic and paper claims accepted with the ability to view all fields instantly at claim review 135,000 claims reviewed a month
85% of claims received are processed by 15 days
100% paperless within 24 hours
Claims
Claims Claims can be assigned daily based on priority,
payment guidelines, or reviewer training/expertise
We review 90% of claims upfront through various custom edits, not “pay and chase”
We have access to secondary networks on a national basis for out-of-network discount negotiations
In-house staff dedicated to COB research, subrogation, and funds recovery
Customer Service
Customer Service All member and provider calls regarding benefits,
claims issues, and eligibility are answered by a ‘live’ person employed and supervised by The Health Plan
Call queues are structured by product line or group
Abandonment rate considered ‘outstanding’ based on industry standards Abandonment Rate for 2014 is 1.65%
(Industry Standard 5%)
Speed of Answer for 2014 is 11 seconds (Industry Standard 30 seconds or higher)
All forms of member contact documented on a “Contact Service Form” in the computer system as they are received and closed when issue is resolved
Customer Service Length of time to resolve issues calculated by system
based on open and close dates
Integrated systems allow customer service staff to view information below to resolve issues quickly: Benefits
Claims History
Correspondence
Eligibility Information
Emails
Dedicated in-house department handles all complaints, appeals, and grievances
1.4% complaints per thousand members per year
Medical Management
Medical Management Utilization Management
14 full time registered nurses with certifications in managed care and care management
Care/Case Management 7 full time registered nurses with certifications in case
management
Disease Management 6 full time registered nurses with certifications in diabetes
education, obstetrics, and advance cardiac life support
Social Work Services 3 full time licensed masters level social workers
Preauthorization of Services
Provides oversight of health care services to members
Ensures services are medically appropriate and promotes access to care in a timely, effective, and efficient manner
Registered nurses help members get the care they need, when they need it, using nationally recognized criteria
Medical directors review any service that does not meet criteria
Hospital Review
Registered nurses receive clinical information from hospitals about member’s care and progress
Monitors quality of care members receive
Assists with discharge planning
Utilization Management
Care/Case Management Care Management – process to assist members in managing their
medical conditions to improve their health status
Registered nurses assist members with ongoing health care needs through regular telephonic contact
Complete comprehensive assessments and establish a care plan with the member and their caregiver
Arrange follow-up to physicians and coordinate services through the sharing of care plans with members and their physicians
Catastrophic Case Management – collaborative process to meet member’s comprehensive health care needs to promote quality, cost effective care
Certified registered nurses in case management that help members to achieve wellness by identifying appropriate providers and available resources
Supports members who have experienced life altering injury or illness such as traumatic brain or spinal cord injury or bone marrow or other solid organ transplant
Serves as the liaison by having direct communications with the member/caregivers, physicians, and providers of service to coordinate care across the continuum
Disease Management Uses nationally recognized evidence-based practice guidelines
for:
Diabetes
Chronic obstructive pulmonary disease (COPD)
Congestive heart failure (CHF)
Prenatal care (high-risk pregnancy)
Supports physician-patient relationship and plan of care through regular telephonic contact
Helps with patient empowerment, self-management, and medication adherence in “Journey for Control” classes, one-on-one educational sessions, and educational material mailings
Emphasizes prevention of exacerbations and complications by educating members with heart failure about weight gain and supplying them with a scale
Social Work Services 3 social workers with hospital, long-term care/rehab, and
community experience
Financial help for medications
Accesses community resources
Provides support and counseling
Other Medical Services Hospital Discharge Follow-up Calls
Registered nurses call members within 48 hours of acute discharge
Assess condition/answer questions
Discuss medications
Assist with follow-up
In-house Nurse Information Line Registered nurses available 24/7
Assist members to urgent or emergent level of care
Assist with out-of-area or emergent care needs
Assist with access to pharmacy or behavioral health benefits
Quality Improvement
External Quality Regulators Responsible for compliance with outside quality
regulators:
National Committee for Quality Assurance (NCQA)
Centers for Medicare & Medicaid Services (CMS and BMS)
Employer groups
Quality standards are applied to ALL Health Plan members regardless of employer group
Healthcare Effectiveness Data and Information Set (HEDIS®)
Clinical practice guidelines
Primary care physician-driven guidelines from nationally recognized sources
Accessibility and availability
Monitoring of a member’s ability to receive services in a timely manner and within reasonable travel distance
Satisfaction of care
Survey driven
Continuity and coordination of care
Quality of care (variances, problems, complaints)
All monitored for compliance to standards. Corrective action plans required when standards not met
Outcomes
Health & Wellness Promotion Telephonic outreach
Encourage members 18 years and older to participate in preventive care
Provides personalized contact with members who are missing important services and/or testing like:
Well care visits and establishing with a PCP
Preventive health services
General and disease-specific discussions
Management of care after an event
Can include any member group
Behavioral Health
Behavioral Health Unit All inclusive unit
Customer Service
Preauthorizations
Utilization Review
Case/Care/Disease Management
Claims Payment
Services directed by evidence-based national guidelines InterQual
Independent Reviewers also use InterQual
Staffed by behavioral health professionals and certified nurses
Provider Network
HP Network Contracted with 113 facilities in primary service area
Contracted with over 14,500 physicians
All contracting and service items (new providers, claims inquiries, questions, etc.) serviced by The Health Plan directly
NCQA Excellent Accreditation
National Network capability through Global Care agreement
Regional and national partnerships providing access to competitive discounts
Provider Network
Tertiary Facilities Include:
Ohio State University
Cleveland Clinic
UPMC Children’s
Allegheny / West Penn
Nationwide Children’s
West Virginia University Hospital
Charleston Area Medical Center
Akron General Medical Center
Children’s Hospital Medical Center of Akron
Information Systems/Web
Information Systems All core systems developed and
maintained in-house allowing for quick modifications/enhancements
Custom core systems include: Care/Case/Disease Management
Claims Adjudication
Enrollment
Medical Utilization
Provider Networking
Plan Design
Information Systems Integrated document imaging system
ties to our core systems and secure web portals
Work with numerous clearinghouses and direct providers to receive HIPAA EDI X12 compliant and noncompliant data formats
All core systems are designed with data and hardware redundancy including a facility-wide generator for 24/7 run-time
SSAE 16/SOC 1 audit performed yearly
Web Capabilities All web portals developed, maintained,
and hosted in-house Website, healthplan.org, features:
Provider search
HRA and other health interactive tools
Information on advance care planning, preventive care, and pharmacy services
Ability to create customized homepages for certain groups
Web Capabilities Secure Member Portal features:
Claims history, dollar and visit limitations
Copay information
Correspondence/EOB
Secure Provider Portal features: Member eligibility and copay amounts
Claim information
Referral information
Secure Enrollment Portal for group administrators
Secure Group and Broker Portal in development for 2014
Established as a community health organization, The Health Plan delivers a clinically driven, technology enhanced, customer-focused platform by developing and implementing products and services that manage and improve the health and well-being of our members. We achieve these results through a team of health care professionals and partners from across our community.
Mission Statement
Thank You
Questions?