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Navigating the Commercial Market & Health Insurance Exchanges
Navigating the Commercial Market & Health Insurance Exchanges
Navigating the Commercial Market & Health Insurance Exchanges
Navigating the Commercial Market & Health Insurance Exchanges
Navigating the Commercial Market & Health Insurance Exchanges
Navigating the Commercial Market & Health Insurance Exchanges
Navigating the Commercial Market & Health Insurance Exchanges
Navigating the Commercial Market & Health Insurance Exchanges
Navigating the Commercial Market & Health Insurance Exchanges
Navigating the Commercial Market & Health Insurance Exchanges
Navigating the Commercial Market & Health Insurance Exchanges
Navigating the Commercial Market & Health Insurance Exchanges
Navigating the Commercial Market & Health Insurance Exchanges
Navigating the Commercial Market & Health Insurance Exchanges
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Navigating the Commercial Market & Health Insurance Exchanges

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Implementation of the Affordable Care Act’s Market Reform Rules is rapidly transforming the commercial exchange market. Success under reform requires an emphasis on: …

Implementation of the Affordable Care Act’s Market Reform Rules is rapidly transforming the commercial exchange market. Success under reform requires an emphasis on:

- Accurate eligibility, claims and coding data
- Risk intelligence under the new Hierarchical Condition Category (HCC) risk model
- Member engagement, assessment and retention
- Provider engagement and incentives
- Precise medical management

Altegra Health’s integrated suite of services assists health plans in managing the commercial market requirements and the resulting market response through:

- Data transformation and submission, risk analytics, and payment transfer reconciliation
- Diagnosis and procedure code coding and primary data validation audit support
- Member onboarding, engagement and retention
- Provider engagement and support
- Care management and medical cost reductions

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  • 1. Commercial  Market  &   Health  Insurance   Exchanges  
  • 2. 2   CHALLENGES  FACING  HEALTH  PLANS  
  • 3. Challenges  Facing  Health  Plans   ! Impact  of  DocumentaCon,  Data  and  Risk  Scoring  on  Revenue   ! Concurrent  risk  model  and  payment  transfers  make  data  accuracy  (claims,  eligibility,   subsidies)  impera:ve   ! ACA-­‐RADV  error  rate  applies  to  annual  funds  transfer   ! Outreach,  Enrollment  and  RetenCon  More  Complex   ! Marke:ng  and  customer  service  impacted  by  complex  choices,  lower  educated  consumers,   high  churn,  confusion   ! Addressing  adjacent  products:  Medicaid,  CHIP,  grandfathered  commercial   ! Challenges  for  Provider  Networks  and  Provider  RelaCons   ! Office  burdens:  volume,  social  needs,  unaccustomed  to  risk  adjustment,  documenta:on   requirements,  ICD-­‐10   ! Health  plan  compe::on  offering  incen:ves  and  support  services  as  differen:ators   ! Care  Management  Challenges   ! Large  numbers,  clinical  needle  in  the  haystack   ! Burdened  by  need  for  financial  and  social  program  support  (Exchange       3  
  • 4. Managing  the  Funds  Transfer  Formula   ! High  HCC  Scores  Create  Economic  Value  When  the  Cost  of  Care  is   Managed   ! Data  Accuracy  Required:  Enrollment,  Claims,  Edge  Server   ! Enrollees  with  High  Costs  and  Missed  HCC’s  Cause  Economic  Loss   ! ACA-­‐RADV  has  Material  Impact   ! Provider  documenta:on  and  claims  processing  is  cri:cal   ! Expect  annual  adjustments   ! Increased  Reliance  on  the  Provider   ! Provider  claims  processing  –  for  risk  adjustment  and  audit   ! Provider  documenta:on  –  for  audit  purposes   ! Provider  coding  errors  –  affects  risk  adjustment  and  audits       4  
  • 5. 5   ALTEGRA  HEALTH  SOLUTIONS  
  • 6. The  Altegra  Health  Difference   ! Deep  Market-­‐Specific  Leadership   ! Successfully  suppor:ng  complex  risk  markets:  Medicaid  and  Medicare  changes;  now   Commercial   ! Member  engagement,  especially  for  low  income  popula:ons   ! Chart  coding  and  provider  educa:on;  Medicaid  Medicare,  RADV  exper:se   ! The  Altegra  Health  Approach   ! Open,  transparent  algorithms  and  analy:cs   ! Providing  all  details  at  member,  provider  and  claim  level   ! Proac:ve,  consulta:ve  account  support  to  improve  results   ! Enhances  member,  provider  and  staff  rela:onships   ! Integrated  PlaTorm   ! Eliminates  data  erosion   ! Communica:on  plaZorm  con:nually  refreshed       6  
  • 7. Altegra  Health  SoluCons  Assist  Commercial  Plans   ! Risk  AnalyCcs  and  Data  TransformaCon   ! Edge  server  data  transforma:on  and  error  management   ! Monthly  risk  trending;  member  and  provider  targe:ng   ! Data  valida:on  and  primary  audits   ! MulC-­‐Channel  Onboarding  and  Engagement   ! New  enrollment  welcome,  reten:on,  health  assessment  and  literacy   ! Social  program  enrollment   ! Physician  visit  coordina:on   ! ProacCve  CoordinaCon  of  Coding  and  EducaCon   ! Analy:c  driven  targe:ng   ! Obtain  and  code  charts   ! Provider  educa:on   ! Member  Care  and  RetenCon   ! Iden:fy  care  gaps   ! Reten:on  of  health  members   ! Compliance  for  chronic  condi:ons  and  appropriate  u:liza:on     7  
  • 8. Take  AcCon  Now   ! Plan  for  Edge  Server  and  Data  TransformaCon   ! Assess  impact  of  data  erosion  and  errors   ! Adjust  infrastructure  to  capture  new  required  data  elements   ! Assess  Current  Commercial  PopulaCon   ! Scoring  and  analy:cs  for  non-­‐grandfathered  current  individual  and  small  group  members   ! Provider  targeted  chart  audit  to  assess  documenta:on  risk   ! Provider  Engagement  Strategy   ! Consider  incen:ves  for  documenta:on  and  chart  access   ! Create  contract  differen:a:on  with  burden  relief:  program  assistance  member  outreach,   documenta:on  training,  coding  support   ! Plan  Outreach  Campaigns   ! Execute  reten:on  strategy  for  grandfathered  products   ! October  1,  2013  -­‐  start  new  enrollee  outreach       8  
  • 9. Altegra  Health  Commercial  Plan  SoluCons   9  
  • 10. 10   RISK  View™  Overview   10   !  Full  edge  server  support   !  Scrubs  data  &  prioriCzes  submission   errors  for  correcCon   !  Analyzes  risk  scores  by:  geography,   metal  level,  provider,  exchange,  non-­‐ exchange   !  Provides  member  details  by  age  bands,   FPL,  reinsurance,  metal  level,   geography,  exchange,  non-­‐exchange,   small  group   !  Customizable  targeCng  algorithms  for   retrospecCve  &  prospecCve  outreach   RISK  View™  coupled  with  ongoing  experCse  and  analysis,     delivers  a  powerful  service  that  dynamically   improves  quality  of  care  and  revenue          
  • 11. SMART  Connect™  Overview   11  
  • 12. CODE  Complete™  Overview   12  
  • 13. COMMUNITY  Link™  Overview   13  
  • 14. AltegraHealth.com   14   for  more  details  and  product  demonstra:ons.   Contact  Altegra  Health   NextSteps@AltegraHealth.com  

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