CBS Managed Care Workgroup RFP Development Kick-Off  Work Session May 13, 2003  9:00 a.m. – 12:15 p.m. Sacramento, Califor...
Agenda <ul><li>Introductions & Agenda Review </li></ul><ul><li>The State of Managed Care in the US  </li></ul><ul><li>What...
The State of Managed Care in the US <ul><li>American Academy of Family Physicians </li></ul>
The State of Managed Care in the US <ul><li>Insurance companies are responding to physician, hospital, consumer, and legis...
The State of Managed Care in the US <ul><li>Behavioral Health Managed Care Companies have been in a huge state of flux. </...
What does Managed Care mean to California Counties? <ul><li>View 1 – Historical Responsibilities </li></ul><ul><ul><li>Man...
What does Managed Care mean to California Counties? <ul><li>View 2 – Functional Responsibilities </li></ul><ul><ul><li>Cal...
 
 
 
 
 
 
What does Managed Care mean to California Counties? <ul><li>Question: How do your workflows differ? </li></ul>
What does Managed Care mean to California Counties? <ul><li>Software Implications for Views 1 & 2 </li></ul><ul><ul><li>So...
An Evolving Vendor Environment  1998 to Now <ul><li>Cavion - CNR Health Milwaukee, WI 800 654-5160 Managed Care CNR is a m...
An Evolving Vendor Environment  1998 to Now <ul><li>Blackberry Technologies 135 West 50th St, Suite 1950 New York, NY 1002...
An Evolving Vendor Environment <ul><li>The success stories are now coming in related to electronic medical records (EMR) p...
An Evolving Vendor Environment <ul><li>Software vendors are learning that past problems haven’t been due to “problem clini...
An Evolving Vendor Environment
An Evolving Vendor Environment <ul><li>We are now seeing second and third  generation solutions and tools that “really  wo...
Current Scope for  Managed Care Workgroup <ul><li>2.0 Functional Requirements </li></ul><ul><ul><li>Each section of the fu...
Current Scope for  Managed Care Workgroup <ul><li>2.1 Access/Call Center </li></ul><ul><ul><li>(To be completed by the Man...
Current Scope for  Managed Care Workgroup <ul><li>2.3 Payor/Provider Management </li></ul><ul><ul><li>(To be completed by ...
Current Scope for  Managed Care Workgroup <ul><li>Question: How do we want to change the Outline to better map  to our nee...
Managed Care - RFP Content Ideas
Managed Care - RFP Content Ideas <ul><li>General Needs (to be found in other parts of the RFP) </li></ul><ul><ul><li>1. Cu...
Managed Care - RFP Content Ideas <ul><li>General Needs (to be found in other parts of the RFP) </li></ul><ul><ul><li>2. Sy...
Managed Care - RFP Content Ideas <ul><li>General Needs (to be found in other parts of the RFP) </li></ul><ul><ul><li>3. Cu...
Managed Care - RFP Content Ideas <ul><li>General Needs (to be found in other parts of the RFP) </li></ul><ul><ul><li>4. Ti...
Managed Care - RFP Content Ideas <ul><li>Call Center </li></ul><ul><ul><li>Call Logging:  All calls are logged into a user...
Managed Care - RFP Content Ideas <ul><li>Call Center </li></ul><ul><ul><li>Intake Screening:  Provides user-defined online...
Client Screening
Client Screening
Managed Care - RFP Content Ideas <ul><li>Call Center </li></ul><ul><ul><li>Case Notes: Supports the entry of case notes fo...
Managed Care - RFP Content Ideas <ul><li>Crisis Tracking and Management </li></ul><ul><ul><li>Crisis Plan:  Supports the d...
Crisis Plans
Managed Care - RFP Content Ideas <ul><li>Crisis Tracking and Management </li></ul><ul><ul><li>Crisis Investigation:  Suppo...
Managed Care - RFP Content Ideas <ul><li>Authorization and Utilization Management </li></ul><ul><ul><li>Authorizations:  A...
Managed Care - RFP Content Ideas <ul><li>Authorization and Utilization Management </li></ul><ul><ul><li>Authorization Limi...
Authorization & Referral Tracking
Managed Care - RFP Content Ideas <ul><li>Authorization and Utilization Management </li></ul><ul><ul><li>Caseload and Utili...
Clinician Caseload Tracking
Managed Care - RFP Content Ideas <ul><li>Care Management </li></ul><ul><ul><li>Inpatient Tracking and Management:  Provide...
Admission Tracking
Census Tracking
Managed Care - RFP Content Ideas <ul><li>Care Management </li></ul><ul><ul><li>Allows for the development of user-defined ...
Treatment Planning
Service Review & Discharge Planning
Managed Care - RFP Content Ideas <ul><li>Care Management </li></ul><ul><ul><li>Other </li></ul></ul><ul><ul><li>Other </li...
Managed Care - RFP Content Ideas <ul><li>Provider Relations and Management  </li></ul><ul><ul><li>Contracts:  Support mult...
Managed Care - RFP Content Ideas <ul><li>Provider Relations and Management  </li></ul><ul><ul><li>Expiration Alerts:  Has ...
Managed Care - RFP Content Ideas <ul><li>Provider Relations and Management </li></ul><ul><ul><li>Inpatient Consolidation M...
Managed Care - RFP Content Ideas <ul><li>Provider Relations and Management </li></ul><ul><ul><li>Other </li></ul></ul><ul>...
Managed Care - RFP Content Ideas <ul><li>Claims Processing </li></ul><ul><ul><li>Claims Receipt:  Allows for the entry of ...
Managed Care - RFP Content Ideas <ul><li>Claims Processing </li></ul><ul><ul><li>EOBs:  Generates Explanation of Benefits ...
Managed Care - RFP Content Ideas <ul><li>Claims Processing </li></ul><ul><ul><li>Other </li></ul></ul><ul><ul><li>Other </...
Next Steps <ul><li>Email any follow-up ideas. </li></ul><ul><li>Decide how to gather feedback from colleagues inside your ...
Choosing a Workgroup Lead
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MCPP HEALTHCARE CONSULTING CBS Managed Care Workgroup RFP ...

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MCPP HEALTHCARE CONSULTING CBS Managed Care Workgroup RFP ...

  1. 1. CBS Managed Care Workgroup RFP Development Kick-Off Work Session May 13, 2003 9:00 a.m. – 12:15 p.m. Sacramento, California Dale Jarvis CPA
  2. 2. Agenda <ul><li>Introductions & Agenda Review </li></ul><ul><li>The State of Managed Care in the US </li></ul><ul><li>What does Managed Care mean to California Counties? </li></ul><ul><li>An Evolving Vendor Environment </li></ul><ul><li>Current Scope of Work for our Workgroup </li></ul><ul><li>Managed Care - RFP Content Ideas </li></ul><ul><li>Next Steps </li></ul><ul><li>Choosing Workgroup Lead & Backup </li></ul>
  3. 3. The State of Managed Care in the US <ul><li>American Academy of Family Physicians </li></ul>
  4. 4. The State of Managed Care in the US <ul><li>Insurance companies are responding to physician, hospital, consumer, and legislator pressure. </li></ul><ul><li>“ If you hate managed care, so be it. We’ll move out of the access and utilization management business and go back to our original mission – using actuaries to price policies and then managing the flow of payor premiums and payor claims.” </li></ul><ul><li>This is resulting in commercial insurance premium increases this year in the 20% – 30% range. </li></ul>
  5. 5. The State of Managed Care in the US <ul><li>Behavioral Health Managed Care Companies have been in a huge state of flux. </li></ul><ul><li>Magellan Behavioral Health acquired almost all of their competitors and is now is bankruptcy. </li></ul><ul><li>Most MBHO’s have gotten out of the Public Sector: </li></ul><ul><li>Magellan has had contracts pulled. </li></ul><ul><li>United Behavioral Health has close to zero remaining public sector contracts. </li></ul><ul><li>Value Options has scaled their public sector division back and also has fewer contracts </li></ul>
  6. 6. What does Managed Care mean to California Counties? <ul><li>View 1 – Historical Responsibilities </li></ul><ul><ul><li>Management of Organizational Providers </li></ul></ul><ul><ul><li>Management of County Operated Programs </li></ul></ul><ul><ul><li>Inpatient Consolidation – Management of Institutional Providers </li></ul></ul><ul><ul><li>Outpatient Consolidation – Management of Individual Providers & Small Groups </li></ul></ul>
  7. 7. What does Managed Care mean to California Counties? <ul><li>View 2 – Functional Responsibilities </li></ul><ul><ul><li>Call Center </li></ul></ul><ul><ul><li>Crisis Tracking and Management </li></ul></ul><ul><ul><li>Authorization and Utilization Management </li></ul></ul><ul><ul><li>Care Management (Outpatient and 24 hr Svcs) </li></ul></ul><ul><ul><li>Provider Relations and Management </li></ul></ul><ul><ul><li>Claims Processing </li></ul></ul>
  8. 14. What does Managed Care mean to California Counties? <ul><li>Question: How do your workflows differ? </li></ul>
  9. 15. What does Managed Care mean to California Counties? <ul><li>Software Implications for Views 1 & 2 </li></ul><ul><ul><li>Software has to match the workflows of these responsibilities and activities. </li></ul></ul><ul><ul><li>Software has to “roll with the punches”; different counties do this work differently and have different business rules. </li></ul></ul><ul><ul><li>Software needs to support both clinical activities and business activities. </li></ul></ul><ul><ul><li>Software should promote “paperwork reduction initiatives” and make life easier rather than harder for staff. </li></ul></ul><ul><ul><li>Software should improve the quality of client care. </li></ul></ul>
  10. 16. An Evolving Vendor Environment 1998 to Now <ul><li>Cavion - CNR Health Milwaukee, WI 800 654-5160 Managed Care CNR is a managed care company that has becoming a software vendor for the managed care product they’ve been using in-house. The system runs on SQL Server and they are working on adding Oracle. The software manages about 2,000,000+ lives. </li></ul><ul><li>Diamond Health Systems Design 1330 Broadway Oakland California 800 995-6285 Managed Care This is a healthcare system. A number of counties in California are using it for their healthcare needs and three are using it for mental health. They have a character-based version and a Windows version. They have integrated their product with SMS. </li></ul><ul><li>Emcee Managed Care Info System - Mariner Systems 2336 Canyon Boulevard, Suite 201 Boulder, Co 80302 (800)242-8845 Managed Care They have a newish managed care product that was built for medical and is starting to be installed in a number of mental health settings. They have the right technology and have started to make links into provider systems and accounting systems. </li></ul>
  11. 17. An Evolving Vendor Environment 1998 to Now <ul><li>Blackberry Technologies 135 West 50th St, Suite 1950 New York, NY 10020 (212) 246-7200 Managed Care They have managed care software. Folks at OTG have spoken with them before about their product. Their system is supposed to be an odd design because they don’t have deep mental health experience and listen to what their clients need, regardless of how strange the request may be. They have the right technology and are a talented bunch. </li></ul><ul><li>In-Net - Aurora CMHC Aurora, Colorado (303)617-2300 Managed Care and Practice Management This group came out of a consortium of two hospitals and several CMHCs in Colorado who funded the development of managed care and provider systems using new technology. I don’t know if they have the infrastructure to be viable. </li></ul><ul><li>Ecura - InfoMC 2250 Hickory Road, Ste 400, Plymouth Meeting PA 19462 (484) 530-0100 Managed Care You know these guys… </li></ul>
  12. 18. An Evolving Vendor Environment <ul><li>The success stories are now coming in related to electronic medical records (EMR) projects: </li></ul><ul><ul><li>Seventh Annual Davies CPR Recognition Award The Ohio State University Health System University of Illinois at Chicago Medical Center Heritage Behavioral Health Center, Inc. </li></ul></ul><ul><ul><li>Sixth Annual Davies CPR Recognition Award Harvard Vanguard Medical Associates/Harvard Pilgrim Healthcare Department of Veterans Affairs: Puget Sound Health Care System St. Vincent's Psychiatric Hospital </li></ul></ul><ul><ul><li>Fifth Annual Davies CPR Recognition Award The Queen's Medical Center Kaiser Permanente Rocky Mountain Region </li></ul></ul>
  13. 19. An Evolving Vendor Environment <ul><li>Software vendors are learning that past problems haven’t been due to “problem clinicians”, but to hardware and software products that were just too “clunky”. </li></ul>
  14. 20. An Evolving Vendor Environment
  15. 21. An Evolving Vendor Environment <ul><li>We are now seeing second and third generation solutions and tools that “really work” and are being used by more and more clinicians. </li></ul>
  16. 22. Current Scope for Managed Care Workgroup <ul><li>2.0 Functional Requirements </li></ul><ul><ul><li>Each section of the functional requirements will have: </li></ul></ul><ul><ul><li>One or more descriptive paragraphs </li></ul></ul><ul><ul><li>Numbered, high-level functionality components that should exist in most well designed software packages. </li></ul></ul><ul><ul><li>Numbered, more detailed California County-specific functionality components. </li></ul></ul><ul><ul><li>Limiting the number of components that should be in most packages is the key to a &quot;right-sized&quot; RFP. </li></ul></ul>
  17. 23. Current Scope for Managed Care Workgroup <ul><li>2.1 Access/Call Center </li></ul><ul><ul><li>(To be completed by the Managed Care Workgroup) </li></ul></ul><ul><ul><li>This section contains functionality related to how the “front door” needs to be managed including call logging, provider referral, crisis triage, etc. </li></ul></ul><ul><li>2.2 Eligibility Verification </li></ul><ul><ul><li>(To be completed by the Billing/Accounting Workgroup) </li></ul></ul><ul><ul><li>This section contains info on the variety of ways that eligibility should be verified, following how InSyst does this as well as future improvements. </li></ul></ul>
  18. 24. Current Scope for Managed Care Workgroup <ul><li>2.3 Payor/Provider Management </li></ul><ul><ul><li>(To be completed by the Managed Care Workgroup) </li></ul></ul><ul><ul><li>This section describes functionality related to how county and external providers are set up in the system, how provider credentialing is managed, as well as how external claims are processed. </li></ul></ul><ul><li>2.4 Utilization and Care Management </li></ul><ul><ul><li>(To be completed by the Managed Care Workgroup) </li></ul></ul><ul><ul><li>This section focuses on describing the use of authorizations in a manner that provides enough flexibility so that they will meet the varying needs of all the counties. </li></ul></ul>
  19. 25. Current Scope for Managed Care Workgroup <ul><li>Question: How do we want to change the Outline to better map to our needs? </li></ul><ul><ul><li>Call Center </li></ul></ul><ul><ul><li>Crisis Tracking and Management </li></ul></ul><ul><ul><li>Authorization and Utilization Management </li></ul></ul><ul><ul><li>Care Management (Outpatient and 24 hr Services) </li></ul></ul><ul><ul><li>Provider Relations and Management </li></ul></ul><ul><ul><li>Claims Processing </li></ul></ul>2.1 Access/Call Center 2.3 Payor/Provider Management 2.4 Utilization and Care Management
  20. 26. Managed Care - RFP Content Ideas
  21. 27. Managed Care - RFP Content Ideas <ul><li>General Needs (to be found in other parts of the RFP) </li></ul><ul><ul><li>1. Custom Forms: The system has the ability to allow for the development of custom forms for Managed Care - Client Services, Managed Care - Payor/Provider Relations; Practice Management - Client Services. The forms will allow for the creation of new fields. They will support validation checks for all new and existing fields and user-defined determination of entry rules (e.g. required, warning, not required/no warning). Each field will have various field types: text, radio button, checklist, and fields populated by user-defined lookup tables. </li></ul></ul>
  22. 28. Managed Care - RFP Content Ideas <ul><li>General Needs (to be found in other parts of the RFP) </li></ul><ul><ul><li>2. System Navigation: Provides the ability throughout the system to either go back to the menu to move to another screen or to have user-defined buttons on the screen that will prompt the user to go to another form. The system allows for all information relating to a particular client, provider, care manager, member, etc.. to be easily accessed from any screen in the system where such data exists (e.g. be able to go to authorizations or call logs or screening forms from service entry or progress note entry). 3. Provides the ability throughout the system to either go back to the menu to move to another screen or to have user-defined buttons on the screen that will prompt the user to go to another form. </li></ul></ul>
  23. 29. Managed Care - RFP Content Ideas <ul><li>General Needs (to be found in other parts of the RFP) </li></ul><ul><ul><li>3. Custom Reports: The system can generate any number of custom forms that can be place on menus in user-defined locations. Has the capability of reporting on any group of data fields in the entire BHIS including user-defined fields; can perform multi-layered sorts and selects; has the ability to utilize wild cards in any data position of a field to select items; has the ability to compute on any field or group of fields. Has a report designer to design how reports will look and support a number of reports including columnar, cross-tab, mailing labels, form letters, graphs, etc. Has the options of outputting reports on an manual or automated basis to the screen, printer, standard ASCII file format and PC application formats (XLS, WK*, MDB, DIF, etc.) </li></ul></ul>
  24. 30. Managed Care - RFP Content Ideas <ul><li>General Needs (to be found in other parts of the RFP) </li></ul><ul><ul><li>4. Tickler Engine: A system that allow for fields to be added in any form that allow the user to specify if follow-up is needed and when (&quot;in xx days&quot;, or &quot;on xx date. In addition a tickler attribute can be added to most fields throughout the system whereby a user can set a value for that field (e.g. &quot;a billed item has had no payment action in 45 days&quot; or &quot;it has been 7 days since the form that holds this item was filled out but this required field is still blank&quot;). The tickler engine can be set to run at specified intervals (e.g. &quot;every night at 1am&quot; and when it finds a record that meets the tickler threshold the engine will initiate a predetermined action that was originally set up. These actions include: Send an email to the case manager or designated billing person or the supervisor, etc. Add the item to a report that is automatically printed at the end of the process, sorted by type of tickler item. Add the item to a report that is manually run by various users (e.g. &quot;the scheduling person runs the report of all appointments from the previous day that have not had some action entered&quot;) </li></ul></ul>
  25. 31. Managed Care - RFP Content Ideas <ul><li>Call Center </li></ul><ul><ul><li>Call Logging: All calls are logged into a user-defined online form that gathers information on the nature of the call and basic caller data such as name, phone number, language requirement, etc. If the call is not a request for service, basic information is collected regarding the type of call and disposition. If the call is about a complaint, compliment or grievance, all relevant data is recorded on the online form. Recording and reporting of disposition is included in all cases. </li></ul></ul><ul><ul><li>Pre-Registration: Provides user-defined online pre-registration forms to gather initial client demographic and financial resources information for individuals requesting service. If the client becomes registered for service this information can be forwarded to Registration so that duplicate data entry is not required. If the client is already registered as a client in the system this should be flagged. </li></ul></ul>
  26. 32. Managed Care - RFP Content Ideas <ul><li>Call Center </li></ul><ul><ul><li>Intake Screening: Provides user-defined online client screening forms to assist in the determination of whether the client requires services from the crisis system, hospitalization, referral for outpatient services, or referral to other community resources. Includes access needs information, presenting problems and other relevant clinical information. </li></ul></ul><ul><ul><li>Referral Database: Contains detailed information about the practices of clinicians in the provider network (including county staff clinicians) and facilitates the matching of client to clinician through the selection of criteria in the provider database. This includes information about provider location, specialties, non-English language capability, etc. </li></ul></ul>
  27. 33. Client Screening
  28. 34. Client Screening
  29. 35. Managed Care - RFP Content Ideas <ul><li>Call Center </li></ul><ul><ul><li>Case Notes: Supports the entry of case notes for clients that can become part of the chart (as opposed to a call log record) </li></ul></ul><ul><li>Call Center </li></ul><ul><ul><li>Other: </li></ul></ul><ul><ul><li>Other: </li></ul></ul><ul><ul><li>Other: </li></ul></ul>
  30. 36. Managed Care - RFP Content Ideas <ul><li>Crisis Tracking and Management </li></ul><ul><ul><li>Crisis Plan: Supports the development of an online Crisis Management Plan that is prepared for clients of the service delivery system. If a client goes into crisis this plan is available to provide guidance to staff. </li></ul></ul><ul><ul><li>Crisis Intake: Provides user-defined screens for tracking key crisis service data including date and time of initial request, date and time of first contact, referral source, location of service, and type of service as well as clinical notes about the crisis including user-defined checklists and text-based crisis notes that allow for the recording of diagnosis, level of functioning and other relevant clinical data. </li></ul></ul>
  31. 37. Crisis Plans
  32. 38. Managed Care - RFP Content Ideas <ul><li>Crisis Tracking and Management </li></ul><ul><ul><li>Crisis Investigation: Supports the tracking and reporting of data elements related to the involuntary detention law. </li></ul></ul><ul><ul><li>Crisis Referrals: Supports the referral of clients to inpatient facilities, crisis respite, walk-in outpatient care, and assignment to an outpatient authorization. </li></ul></ul><ul><ul><li>Other: </li></ul></ul><ul><ul><li>Other: </li></ul></ul><ul><ul><li>Other: </li></ul></ul>
  33. 39. Managed Care - RFP Content Ideas <ul><li>Authorization and Utilization Management </li></ul><ul><ul><li>Authorizations: Allows for the issuance, tracking and closing of a variety of authorization types (e.g. acute inpatient, IMD, intensive outpatient) that constitute discreet episodes of care. Can support several methods of setting service limits for each type of authorization including number of visits or days, number of client or clinician service hours, number of days or weeks, or specific dollar limits. As service is provided actual services are compared with authorized amounts and the system has multiple ways of notifying providers and utilization managers of remaining balances. </li></ul></ul><ul><ul><li>Authorization Letters: Generates user-customizable authorization letters for providers and clients. Transmits authorization information to providers in a variety of ways including notification to users of the system, EDI, fax, email, as well as generating hard copy referrals. Can transmit a single authorization to multiple individuals and/or organizations. </li></ul></ul>
  34. 40. Managed Care - RFP Content Ideas <ul><li>Authorization and Utilization Management </li></ul><ul><ul><li>Authorization Limits: Can be configured to use authorization limits for information reporting purposes, to generate alerts for care managers and providers, and to stop payment of claims. These options can be applied globally, to specific classes of providers, or to individual clinicians. </li></ul></ul><ul><ul><li>Authorization Tracking: Tracks authorizations in a number of ways including individual and aggregate services authorized, services utilized, and service balances. Generates reports to notify care managers or providers of upcoming authorization end dates and/or authorizations that are approaching their limits. </li></ul></ul>
  35. 41. Authorization & Referral Tracking
  36. 42. Managed Care - RFP Content Ideas <ul><li>Authorization and Utilization Management </li></ul><ul><ul><li>Caseload and Utilization Reporting: Provides reports for individual clinicians and supervisor roll-ups that report caseload statistics and services provided to those clients. </li></ul></ul><ul><ul><li>Ad Hoc Analysis: Supports various ad hoc utilization management activities including random chart pull selection, online chart review, identification of utilization outliers, etc. </li></ul></ul>
  37. 43. Clinician Caseload Tracking
  38. 44. Managed Care - RFP Content Ideas <ul><li>Care Management </li></ul><ul><ul><li>Inpatient Tracking and Management: Provides user-define screens for tracking key inpatient data including date of admission, referring provider, inpatient case manager, outpatient authorization type, outpatient case manager, and date of discharge, admit and discharge diagnosis, legal status, etc. </li></ul></ul><ul><ul><li>Admission and Census Reporting: Supports the production of daily census reports and bed statistics reports. </li></ul></ul>
  39. 45. Admission Tracking
  40. 46. Census Tracking
  41. 47. Managed Care - RFP Content Ideas <ul><li>Care Management </li></ul><ul><ul><li>Allows for the development of user-defined data fields to automate the individual treatment and discharge plans. </li></ul></ul>
  42. 48. Treatment Planning
  43. 49. Service Review & Discharge Planning
  44. 50. Managed Care - RFP Content Ideas <ul><li>Care Management </li></ul><ul><ul><li>Other </li></ul></ul><ul><ul><li>Other </li></ul></ul><ul><ul><li>Other </li></ul></ul>
  45. 51. Managed Care - RFP Content Ideas <ul><li>Provider Relations and Management </li></ul><ul><ul><li>Contracts: Support multiple contractor agreements that include services funded by multiple payors with differing benefit designs and multiple reimbursement systems (e.g. case rate, fee for service, capitation, fixed fee payments). </li></ul></ul><ul><ul><li>Clinician Characteristics: Has user-defined screens to register, track and report on internal and external clinicians, including such information as location, licensure, language, days and times worked, specialties, etc. </li></ul></ul><ul><ul><li>Credentialing: Allows for the credentialing of individual clinicians (internal and external) and the certification of provider facilities. </li></ul></ul>
  46. 52. Managed Care - RFP Content Ideas <ul><li>Provider Relations and Management </li></ul><ul><ul><li>Expiration Alerts: Has user-defined alerts and tickler systems to support the notification of expiring licenses, recredentialing deadlines and other time-sensitive information. </li></ul></ul><ul><ul><li>Provider Notes: Has the ability to record and track communications with provider organizations and individual clinicians including provider requests and complaints and includes a tickler system for ensuring follow-up of outstanding items. </li></ul></ul>
  47. 53. Managed Care - RFP Content Ideas <ul><li>Provider Relations and Management </li></ul><ul><ul><li>Inpatient Consolidation Managed Care: Supports the per diem payment structure for inpatient services provided by participating and out of area inpatient facilities. Needs to support multiple contract agreements for per diem and pro fees. Supports tracking and management of benefit limits, copays, deductibles, covered and non-covered services, and multiple fee schedules. Supports management of multiple payor contracts. Captures insurance benefit rules. Other </li></ul></ul><ul><ul><li>Outpatient Consolidation Managed Care: Supports the external network fee-for-service system for individual clinicians who contract with the Counties. Needs to support multiple contract agreements. Supports tracking and management of benefit limits, copays, deductibles, covered and non-covered services, and multiple fee schedules. Supports management of multiple payor contracts. Supports multiple reimbursement systems (fee for services, case rate, capitation). Captures insurance benefit rules. </li></ul></ul>
  48. 54. Managed Care - RFP Content Ideas <ul><li>Provider Relations and Management </li></ul><ul><ul><li>Other </li></ul></ul><ul><ul><li>Other </li></ul></ul><ul><ul><li>Other </li></ul></ul>
  49. 55. Managed Care - RFP Content Ideas <ul><li>Claims Processing </li></ul><ul><ul><li>Claims Receipt: Allows for the entry of HCFA 1500s and UB92s from network providers (including billed amounts, copays, deductibles, and reason codes) through easy to use data entry screen(s). </li></ul></ul><ul><ul><li>Claims Adjudication: Adjudicates claims on a per claim basis. Claims are screened for proper eligibility including whether other insurance plans are primary, the existence of an appropriate authorization, coverage for the specific service under the authorization and service by an authorized provider. </li></ul></ul><ul><ul><li>Pending/Denying Claims: Can be configured to allow for pending claims for review or to deny the claims if they do not have an appropriate authorization in the system. The user can choose to include or exclude denials and pended claims from Explanation of Benefit (EOB) reports. </li></ul></ul>
  50. 56. Managed Care - RFP Content Ideas <ul><li>Claims Processing </li></ul><ul><ul><li>EOBs: Generates Explanation of Benefits (EOB) reports that detail the disposition of the current claims that have been processed. The EOBs will include all claims entry information (including billed amounts, copays, deductibles, allowed amounts and reason codes) and claim line numbers and unique EOB numbers. </li></ul></ul><ul><ul><li>Claim Reports: Can produce claim reports that are user defined to include or exclude paid, pending and denied claim information for specific providers or facilities or ranges of providers/facilities. </li></ul></ul><ul><ul><li>Claim Adjustments: Can support the entry of claim adjustments where claims that have been entered, adjudicated, approved and paid can be reversed. These adjustments will also be included in the EOBs for specific providers/facilities. </li></ul></ul>
  51. 57. Managed Care - RFP Content Ideas <ul><li>Claims Processing </li></ul><ul><ul><li>Other </li></ul></ul><ul><ul><li>Other </li></ul></ul><ul><ul><li>Other </li></ul></ul>
  52. 58. Next Steps <ul><li>Email any follow-up ideas. </li></ul><ul><li>Decide how to gather feedback from colleagues inside your organization and your provider network. </li></ul><ul><li>Get ready to review and comment on your RFP Sections. </li></ul><ul><li>Begin thinking about demo scenarios. </li></ul>
  53. 59. Choosing a Workgroup Lead
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