5 Keys to Medicare Expansion Approval

PROVIDING POWERFUL SOLUTIONS I Since 2003 I www.QuestAnalytics.com I 920.739.4552 I ©2013
P R O V I D I N G P O W E R F U L S O L U T I O N S

Lock Smiths
Robert Smith
Account Manager, West Region
Robert.Smith@QuestAnalytics.com
Linda Borths
Director of Sales
Linda.Borths@QuestAnalytics.com
John Weis
President & Co-Founder
John.Weis@QuestAnalytics.com
Darren Huff
Account Manager, East Region
Darren.Huff@QuestAnalytics.com

What We’ll Cover Today
The CMS Process
Know Your Deficiencies
Market Providers
Call The Lock Smith
HSD Automation

Key #1 ~ The Key Keeper
Understanding CMS’ Process

Minimum number of providers
• Must contract with sufficient numbers of each
provider specialty type
• Must contract with sufficient number of each HSD
facility type
Maximum Travel Time & Distance to
Providers/Facilities
•90% of beneficiaries have access to at least one
provider/facility
•Contracted providers are not limited to the boundaries of
the county or counties as long as the provider is within
the time & distance requirements.
ADEQUACY Methodology
KEYNOTE
Contracted providers are not limited to the boundaries
of the county or counties as long as the provider is
within the time & distance requirements.

What Happens to Your HSD Tables

2014 PROVIDER T/D Requirements
Time
(minutes)
Distance
(miles)
Time
(minutes)
Distance
(miles)
Time
(minutes)
Distance
(miles)
Time
(minutes)
Distance
(miles)
Time
(minutes)
Distance
(miles)
001 General Practice
002 Family Practice
003 Internal Medicine
004 Geriatrics
005 Primary Care - Physician
006 Primary Care - Nurse
S03 Primary Care 10 5 15 10 30 20 40 30 70 60
007 Allergy and Immunology 30 15 45 30 80 60 90 75 125 110
008 Cardiology 20 10 30 20 50 35 75 60 95 85
010 Chiropractor 30 15 45 30 80 60 90 75 125 110
011 Dermatology 20 10 45 30 60 45 75 60 110 100
012 Endocrinology 30 15 60 40 100 75 110 90 145 130
013 ENT/Otolaryngology 30 15 45 30 80 60 90 75 125 110
014 Gastroenterology 20 10 45 30 60 45 75 60 110 100
015 General Surgery 20 10 30 20 50 35 75 60 95 85
016 Gynecology, OB/GYN 30 15 45 30 80 60 90 75 125 110
017 Infectious Diseases 30 15 60 40 100 75 110 90 145 130
018 Nephrology 30 15 45 30 80 60 90 75 125 110
019 Neurology 20 10 45 30 60 45 75 60 110 100
020 Neurosurgery 30 15 60 40 100 75 110 90 145 130
021 Oncology - Medical, Surgical 20 10 45 30 60 45 75 60 110 100
022 Oncology - Radiation/Radiation Oncology30 15 60 40 100 75 110 90 145 130
023 Ophthalmology 20 10 30 20 50 35 75 60 95 85
025 Orthopedic Surgery 20 10 30 20 50 35 75 60 95 85
026 Physiatry, Rehabilitative Medicine30 15 45 30 80 60 90 75 125 110
027 Plastic Surgery 30 15 60 40 100 75 110 90 145 130
028 Podiatry 20 10 45 30 60 45 75 60 110 100
029 Psychiatry 20 10 45 30 60 45 75 60 110 100
030 Pulmonology 20 10 45 30 60 45 75 60 110 100
031 Rheumatology 30 15 60 40 100 75 110 90 145 130
033 Urology 20 10 45 30 60 45 75 60 110 100
034 Vascular Surgery 30 15 60 40 100 75 110 90 145 130
035 Cardiothoracic Surgery 30 15 60 40 100 75 110 90 145 130
2014 Provider Time and Distance Requirements
Metro Micro Rural
Specialty
Geographic Type
CEACLarge Metro
CMS Code

2014 FACILITY T/D Requirements
Number/
1,000
Maximum
Time
(minutes)
Maximum
Distance
(miles)
Number/
1,000
Maximum
Time
(minutes)
Maximum
Distance
(miles)
Number/
1,000
Maximum
Time
(minutes)
Maximum
Distance
(miles)
Number/
1,000
Maximum
Time
(minutes)
Maximum
Distance
(miles)
Number/
1,000
Maximum
Time
(minutes)
Maximum
Distance
(miles)
040 Acute Inpatient Hospitals 12.2 20 10 12.2 45 30 12.2 80 60 12.2 75 60 12.2 110 100
041 Cardiac Surgery Program NA 30 15 NA 60 40 NA 160 120 NA 145 120 NA 155 140
042 Cardiac CatheterizationServices NA 30 15 NA 60 40 NA 160 120 NA 145 120 NA 155 140
043 CriticalCare Services – Intensive Care Units (ICU) NA 20 10 NA 45 30 NA 160 120 NA 145 120 NA 155 140
044 Outpatient Dialysis NA 20 10 NA 45 30 NA 65 50 NA 55 50 NA 100 90
045 SurgicalServices (Outpatient or ASC) NA 20 10 NA 45 30 NA 80 60 NA 75 60 NA 110 100
046 SkilledNursingFacilities NA 20 10 NA 45 30 NA 80 60 NA 75 60 NA 95 85
047 Diagnostic Radiology NA 20 10 NA 45 30 NA 80 60 NA 75 60 NA 110 100
048 Mammography NA 20 10 NA 45 30 NA 80 60 NA 75 60 NA 110 100
049 PhysicalTherapy NA 20 10 NA 45 30 NA 80 60 NA 75 60 NA 110 100
050 OccupationalTherapy NA 20 10 NA 45 30 NA 80 60 NA 75 60 NA 110 100
051 SpeechTherapy NA 20 10 NA 45 30 NA 80 60 NA 75 60 NA 110 100
052 Inpatient Psychiatric Facility Services NA 30 15 NA 70 45 NA 100 75 NA 90 75 NA 155 140
054 Orthotics andProsthetics NA 30 15 NA 45 30 NA 160 120 NA 145 120 NA 155 140
055 Home Health NA NA NA NA NA
056 Durable MedicalEquipment NA NA NA NA NA
057 Outpatient Infusion/Chemotherapy NA 20 10 NA 45 30 NA 80 60 NA 75 60 NA 110 100
061 Heart Transplant Program NA NA NA NA NA
062 Heart/LungTransplant NA NA NA NA NA
064 Kidney Transplant Program NA NA NA NA NA
065 Liver Transplant Program NA NA NA NA NA
066 LungTransplant Program NA NA NA NA NA
067 Pancreas Transplant Program NA NA NA NA NA
2014 Provider Time and Distance Requirements
Specialty
Geographic Type
Micro Rural CEACLarge Metro Metro
CMS Code

Network Adequacy OUTPUT (ACC)

A Quest Analytics Exclusive
2007 CMS Partnership Begins with Part D
2009 CMS Partnership Expands to Part C
2012 Medicare Standards Required for Dual
Demonstration Projects
2012 CMS Integrates Server Version
2013 Network Adequacy at the Forefront of Qualifying
and Monitoring Plans for the Exchanges
*CMS Requirements Subject to Change Each CY

BUILT with VISION
QUEST ANALYTICS SUITE™
The industry's only software solution that has continued to
evolve to meet the changing demands of Network
Adequacy. The Quest Analytics Suite fully integrates;
Access, Disruption, Network Adequacy (Medicare and
Custom), Address-level Geocoding and Hospital Quality
Analysis into one easy to use suite.

 ACCESS ANALYSIS
 Access Analysis I Access Comparison I Mapping
 ADEQUACY ANALYSIS
 Medicare Advantage I Medicaid I Dual Eligibles I Exchanges I
Commercial
 GEOCODER & DATA STANDARDIZATION
 Address-Level Accuracy I Data Standardization I Zip Correction
 DISRUPTION ANALYSIS
 Transparency & Confidence I Provider Change Analysis
 QUALITY NETWORK ANALYSIS
 Hospital Quality I Tiered Networks
QUEST ANALYTICS SUITE ™

Key #2 ~ Verify the Lock
Understanding Your Deficiencies

The Power of One
 NO need for County or SSA
Code in data
 NO push pins and
radius rings
 NO Google/MapQuest
searches
All you need is:
ONE RECORD
Per:
Provider/Location/Specialty
Field Requirements
Name, Address, City, State, Zip,
CMS Code, NPI.

Key #3 ~ Make a Key Yourself
Understanding Where To Find Your Keys

GAP ANALYSIS & MAPPING

Market Possibilities

Key #4 ~ Call The Locksmith
Understanding How Fill the Deficiencies

About Narrow Networks
 UNDERSTANDING MARKET DRIVERS
Filling Gaps I Service Area Expansion = Narrow
Networks
 PREDICTING COSTS, REVENUES
TIMELINES
Budget Dollars I Resources I In-House or
Contract
 NARROW NETWORK ANALYSIS –
SERVICE
Identifies and Prioritizes Markets
Ranked and Ordered Analysis for Use In:
~Tiered Networks
~Minimizing Exchange Exposure

A NEW MODEL EXPANDS
Ranks providers across various specialties based on impact to
members covered in each geographic area
Focuses on minimum number of providers to meet criteria
Highlights the importance of a single address
Illustrates the impact a provider has across multiple counties
Gives recruiters the ability to prioritize and create incentives for
highly needed providers
Provides insight to the impact an address has to fulfill multiple
specialties

ANALYZING THE GAPS SCORECARD

REVIEWING THE DEFICIENCY

TRIED (but is it true?)

MEASURING IMPACT
Very little
or no impact,
not worth
the effort.
Have an impact, but
would not meet by their
single location.
Any single provider at one of these
locations would provide access to
90% of membership.

VALIDATING THE IMPACT

MEASURING IMPACT across counties

MEASURING IMPACT across addresses

INCORPORATE UTILIZATION/COST/QUALITY

Quality
QUANTITY QUANTITY QUANTITY
NARROW NETWORK
ANALYSIS
NOT
It’s All About The Approval

The Master Key

Automate Your HSD Tables

P R O V I D I N G P O W E R F U L
S O L U T I O N S
P R O V I D I N G P O W E R F U L
S O L U T I O N S
Market Opportunity and Return on Expansion
Following the Money

Revenue Stream
2014 HSD
Reference
File
2014
Reimbursement
Rates

Projected Return On Expansion

Validating the Numbers

What is the Expansion Worth?

As We Depart

We’ll Be In Touch
Robert Smith
Account Manager, West Region
Robert.Smith@QuestAnalytics.com
Linda Borths
Director of Sales
Linda.Borths@QuestAnalytics.com
John Weis
President & Co-Founder
John.Weis@QuestAnalytics.com
Darren Huff
Account Manager, East Region
Darren.Huff@QuestAnalytics.com

5 Keys to Medicare Expansion Approval

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5 Keys to Medicare Expansion Approval