GDS International - Next - Generation - Healthcare - Payers - Summit - US - 3



Achievable Payer Priorities for 2012

Achievable Payer Priorities for 2012



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    GDS International - Next - Generation - Healthcare - Payers - Summit - US - 3 GDS International - Next - Generation - Healthcare - Payers - Summit - US - 3 Document Transcript

    • Achievable Payer Priorities for 2012Whitepaper
    • emids Payer Practiceemids is a healthcare technology solutions and services provider. We provide efficient tactical and strategic solutions throughpartnerships to: 1. Optimize Process in Core & Care systems; 2. Create solutions to Improve Efficiencies; and, 3. Offer Provider- and Member-centric solutionsemids accomplishes this through deep domain experience in the provider and payer space, proven methods and an acceleratedglobal delivery model* to deliver superior solutions.Our core focus  Compliance and Mandates-ICD-10 Transition  BPO Enabled Solutions-Claims Processing/Repair, Appeals and Grievances, Benchmarking and Auditing  Webservices - Connecting Core and Care systems  Care and Core Analytics & Business Intelligence  Managed Care Product Configuration and Implementation  Legacy Systems Modernization-Business Configuration, Interfaces/Extracts and Reporting Application Services Analysis & Business Services, BPO  Migration Analysis  Member/Provider Portals  Core and Care System impact analysis  Mobile Apps  NPI Analysis  EAI Design & Implementation Claims  Mandates, Compliance and Regulatory  E-Solutions (Billing/Broker/Plan) Management Assistance  Customer Service Solutions  Non voice BPO Operations Customer Membership Service Management Core System Business Services, Implementation, Billing & Business Process Custom Development Revenue Core Product Provider and Management Management Management and Business Testing Services Intelligence Financial & Risk Reimbursement Management Management  Core Claims Systems Analytics, UM/  FACETS/QNXT, Argus, NetWorX, Care CM/DM Analytics CareAdvance, MeDecision Implementation Management  Contact Center Analytics  Payer to Provider Interconnectivity Services  Networks Analytics  IT Project Portfolio & Resource Analytics Platform-specific Application Services Business Intelligence & Data Managementemids confidential 2
    • 5-Point Problem Statement Plaguing the Payer Transaction Risk Business Content Management Management Intelligence Management Payer Services Hosting & Member Enrollment Provider Workflow Services Credentialing Eligibility EOB/EOP Settlement Adjudication Repricing Claims Presentment Transactions AdministrationMany healthcare payer solution vendors position themselves as having the one true answer to the problems plans faced in the flowabove. Many payers have invested millions of dollars in making their IT solutions handle the heavy lifting processes. Some keyplayers in the marketplace are:  Argus  TriZetto  VIPS  Emdeon  DST  McKesson  Cerneremids provides services that maximize efficiencies across products and platforms.To ICD or notThe October 2013 deadline for transitioning to ICD-10 is fast approaching, but the alarm is not sounding, just yet. With healthcarereform looming, competitive marketplaces and a stagnant economy, it’s easy to see why payers and payer enabled tech companiesare considering cost-efficient options to survive the ICD-10 transition.As a payer, there are 3 ICD-10 migration options: 1. Upgrade or remediate current systems 2. Replace or consolidate current systems 3. “Neutralize” the transition processemids confidential 3
    • What Is Neutralization?One of the most appealing options is neutralization, which may delay the expense of the transition and reduces the immediateoperational impact. In this option, codes are converted from ICD-10 to ICD-9 outside of the core administration system, using pre-identified crosswalks. Claims are processed as ICD-9 codes.Pros of neutralization  Delays the expense of the transition  Enables minimal compliance within the October 2013 deadline  Minimizes the operational impact of the transitionCons of Neutralization  Limits your ability to leverage the power of ICD-10 to gain a competitive advantage  Risks financial impact o If payments are not clearly defined under current contracts, if model contracts are based on new or old codes (services using DRGs), or if payments are based on maps that may not be equivalent, you may risk losing funds due to inaccurate payments  Increases possible complexity and need for repeatable steps o ICD-9 codes do not perfectly map to ICD-10 codes, using analytics o Still have to complete a second conversion to truly accept ICD-10 codes with your core administrative platform at some point in the future  Lack of refined data o ICD-9 doesn’t offer the rich data required to stratify member populations and drive targeted campaigns based on new evidence-based models. The lack of code detail in ICD-9 also eliminates the ability to refine risk adjustment models, which can be easily accomplished with ICD-10 Question #1 Does your strategy to acquire and maintain membership rely on cost or new benefit plans that offer perceived value?  If your membership strategy is based on innovative new products, neutralization may not be the right choice. Transitioning to ICD-10 can complement your membership strategy by enabling value-based benefits with short- term impact Question #2 Does your strategy rely on sharing risk with providers?  If you plan to share risk with providers, neutralization may not be the right choice. ICD-10’s detailed codes allow you to implement reimbursement programs that include incentives for your network providers to help reduce waste and duplication and improve clinical metrics Question #3 Does your strategy rely on subrogating claims?  If you differentiate between medical and medical health benefits and need more accurate subrogation, neutralization may not be the right choice. ICD-10 includes supplemental codes for “place of occurrence” and “activity” allowing you to more accurately subrogate claimsemids confidential 4
    • Considerations  Understand the true cost of neutralization  Plan for scalability when looking into new systems replacement  Evaluate the business cost to membership, provider and care management, and operations  Evaluate the cost of completing the conversion twice  Identify true timelines to complete neutralization versus remediation  Provide adequate time to build a working crosswalk that can be used to do a better job than just neutralizeACOAccountable Care Organizations (ACOs) are provider- based organizations that take responsibility for meeting the health care needsof a defined population with the goal of simultaneously improving health, improving patient experience and reducing per capitacosts.How providers organize themselves as “accountable” entities is expected to vary based on existing practice structures in a region,population needs or local environmental factors. Within the ACO structure itself (i.e. subject to the direct authority of the ACO’sgovernance), ACOs are likely to vary widely with respect to the components of care delivery directly included. Payers can work ontheir care management systems and network managements systems to capture and measure some key Performance Indicators.Four key improvements from an ACO approach that will yield quick ROI:  Avoidable emergency room visits continue downward trend, 7 percent better than market  Following evidence-based medicine continues to improve, 6 percentage points better than market  Bending medical cost trend, 2 percentage points better than market  Better managing diabetes will improve long-term health and lower medical costsemids confidential 5
    • Health Plan Supports for ACOs  Improve the population health discipline through leading edge IT Solutions harnessing their current in-house solutions  Maintain advanced analytic capabilities, using data from multiple sources and perspectives including claims, surveys, and medical records with benchmarks  Apply experience at evaluating and managing risk  Apply experience at working with diverse provider networksHealth plans must have a leadership and management structure that supports and maximizes the efficiencies of clinical andadministrative systems.Health plans must have defined processes to:  Promote evidenced-based medicine  Report the necessary data to evaluate quality and cost measures – this could incorporate requirements of other programs, such as the Physician Quality Reporting Initiative (PQRI), Electronic Prescribing, and Electronic Health Records, and coordinate careHealth plans must demonstrate they meet patient-centeredness criteria, as determined by the compliance and mandate teams.emids confidential 6
    • Predictive Fiancial Compliance Modeling Performance HIT Health IT EHR, Provider ACO Management Performance and Quality of & Network Care Evidence Care Based Management CareFraud Waste and AbusePayers and providers are aggressively building a super intelligent system to minimize “waste”. Improvements in fraud, waste andabuse can be achieved by combining the best of rules-based tools with innovative pre-pay analytics. Using this combination of rulesand analytics as a real-time monitoring device will be more valuable than ever for our payer partners. One size does not fit all in thiscritical area, so its ideal to develop a proprietary strategy.Prevention helps remove unnecessary costs from healthcare by identifying claim aberrance and catching potentially fraudulent,abusive or wasteful claims early in the claim lifecycle—even pre-adjudication.Key Flags could be  Provider Alerts  Emerging Patterns & Trends  Member Alerts  Duplicate PaymentsFeatures  Multiple fraud-identification tactics detect aberrant claims: o Proprietary database and data mining systems o Data-driven predictive analytics o Clinical aberrancy rules and alerts  Can operate in various positions within the claims life-cycle: o Pre-adjudicationemids confidential 7
    • o Post-adjudication/pre-claim payment o Post-claim payment (retrospective)  Experienced investigators track and analyze abnormal claims data  Automates manual processes  Onsite medical director and staff cliniciansBenefits  Improves savings opportunities by identifying both known and unknown fraud schemes  Adapts to your current and future business needs  Increases likelihood aberrant claims are detected  Saves time and improves efficiencyFeatures  Identifies erroneous payments for deceased or sanctioned providers, as well as those whose medical licenses may not be valid (as well as identifiny known bad addresses)  Recognizes violations of standard/non-controversial coding issues and indisputably aberrant billing practices  Leverages existing payment processes and "group rules" integration to hold or redirect payments for payment integrity review  Validates provider data in real time  Mines data from multiple databases, which are continually refreshed, for greater accuracy and fewer false positivesBenefits  Helps you maintain or expand your profit margin by reducing improper payments  Avoids workflow disruptions and conserves valuable IT resources by capitalizing on existing payment management processes  Helps preserve strong provider networks by avoiding delays for valid provider reimbursements  Reduces wasted time and resources through fewer false positivesemids confidential 8
    • Payer Analytics Provider Profiling • EBM Outcome Tracking • Practice Revenue to Value Indexing • Variance analysis at each severity level (DRG) Care Analytics Risk Prediction •Case Management • Treatment Prediction •Evidence-based disease & condition clinical reference • Integrated care performance data (Therapy to Treatment) •Treatment (Guidelines/Pathways) plan • Drug reference and drug interaction checker tools • RSPC Models or molecular diagnostics (for Specialty Care) Re-ad Propensity Treatment Prediction • Behavioral Health •Risk Classification • Case Analysis and PBM •Continuing Medical Education programs • Raw data from claims, PBMs, laboratories and HRAs •Drug Interaction • Recurrence score model based on specialty • Safety, Quality and Consumer ExperienceLarge payers have a matured BI Shop and are heading into an “interconnective intelligence” space between their providers. More ofthis vertical is being swept by a wave of interoperability needs. Core (claims adjudication systems) and care management systemsare being developed and improved to provide a higher level of analytics.The ideal approach is to identify a comprehensive data model that applies to both the systems. Healthcare payers and providers areusing clinical analytics to lower healthcare. The payer respondents are analyzing data from a wide variety of sources, includinglaboratory data, pharmacy data and claims data. By improving care coordination, through health insurance exchanges and othermeans of data sharing, payers can access information that will help them establish preventive and wellness guidelines, capture andtrack user experience ratings and identify areas in which fraud, waste and abuse can be targeted and eliminated.Clinical analytics can also help reduce healthcare costs by providing data for the creation of integrated wellness programs. Theseprograms may reduce hospital admissions by allowing patients to receive preventive care, which is less expensive than treatmentand interventions. Payer respondents also looking at and analyzing data across all of their insured patients, particularly identifyingcauses that put patients at risk for readmission. Additionally, payer organizations are analyzing data directly tied to the cost of care,including underwriting policies, identifying instances of fraud and abuse, and predictive modeling.One area of data sharing that does not seem to be in place is sharing between payers. Could that be the next wave?Web ServicesWith many components of the Patient Protection and Affordable Care Act already implemented, it is increasingly urgent for payersto successfully complete the transition to a value-driven healthcare system that rewards top performers and high-quality standards.emids confidential 9
    • Integrate Enterprise Systems to Drive Administrative Efficiency and Reduce CostsThe best core enterprise systems automate the benefits administration of payer organizations -- member enrollment, premiumbilling, claims administration, customer service and other functions. The leading care management applications streamline andimprove the delivery of member care, specifically case management, disease management and utilization management.By integrating enterprise systems, health plans can more efficiently manage health programs in new member-centric settings suchas patient-centered medical homes and accountable care organizations.Payers are further integrating core and care management systems with applications that automate administrative tasks and reducemanual configurations associated with network management. These applications improve  contract modeling; and,  price-variation discovery and help avoid the costs of manual intervention further downstreamIdeally, healthcare payers integrate all of these systems with constituent web-based applications that automate transactionprocessing and information exchange with external constituents, thereby enhancing the coordination of benefits and care delivery.Such web applications can markedly improve health plans interaction with consumers, providers, employers and brokers.Leverage Outsourcing and Customer Service only where necessaryBusiness process outsourcing (BPO) presents an additional, highly effective strategy for improving on the gains of integrated,efficient enterprise systems. Medical-loss ratio rules require that at least 80 cents of every premium dollar be spent on direct patientcare, and BPO services can help minimize the amount that payers spend on administration.Administrative efficiency has increased demand for BPO services, prompting 40 percent of the payers to plan on increasingoutsourcing of business processes to drive down costs. Quality is an issue with inexperience and big foot-printed service providers.Cost-effective offshore, onshore and hybrid models can help lower the cost of many administrative functions, including front end-services such as  Imaging  OCR/scanning  Enrollment and  Claims processing  Application hosting and managementsince the benefits can go well beyond lower, more predictable costs.Application services can accelerate implementations, speed the resolution of software issues, and improve software performanceand reliability.Additionally, customer service can be a key differentiator. Successful health plans can improve member loyalty (experience) bydemonstrating concern about their health issues and providing easy, fast access to care. Exceptional customer service can positionpayers to successfully brand their health and wellness programs, assuring members that not only is their doctor looking out forthem, but so is their health plan.Regardless of how healthcare reform evolves, payers will gain competitive advantages and build membership by shifting prioritiestoward streamlining administrative processes, improving patient care management and adopting new healthcare delivery models.emids confidential 10