Improving the Provider Experience Administrative Simplification

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Improving the Provider Experience Administrative Simplification

  1. 1. Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group.Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group. Improving the Provider Experience Administrative Simplification – Collaborative Approach Delivers Results WCBF Lean, Six Sigma and Business Improvement in Healthcare Summit May 12-13 2010, New Orleans Deborah Smith-Fedon Director, Process Performance Program Provider Service Quality, UnitedHealthcare
  2. 2. Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group. Process Performance Program Mutual Benefits WHAT….. The Process Performance Program leverages a provider- focused project model that expands upon a proven Six Sigma-based process improvement methodology. WHY…. To improve 1st Pass Claim Payment Accuracy, Optimize Current Contract Performance, and Improve Hospital and Physician group Relationships. VALUE…. The program recognizes that the combined processes produce discrepancies that are not recognizable when looking at the hospital’s, physician’s and UHC’s systems independently – a partnership approach enables the highest capability of identification. HOW … DMAIC methodology engaged to deliver fact-based results; improve processes in a structured project format.
  3. 3. Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group. Observation IndividualValue 19017115213311495765738191 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0.0 _ X=0.0457 UCL=0.1149 LB=0 Initial = 0.2462 Final = 0.0457 11 1 1 1 1 2007 - 2009 Discrepancy Rate Improvement Process Performance Program Results PROVEN SUCCESSES • 97 projects • Overall shift in the Mean Discrepancy Rate from 24.6% to 4.57% • Average 81% improvement in discrepancy reduction A discrepancy is any time the UHC reimbursement does not match the Hospital or Medical Groups’ expectation.
  4. 4. Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group. Comparison of Initial & Final Discrepancy Rate Paired T for Final Proportion - Initial Proportion N Mean StDev SE Mean Final Prop 97 0.045691 0.026871 0.002728 Initial Prop 97 0.246237 0.177578 0.018030 Difference 97 -0.200546 0.173079 0.017573 95% CI for mean difference: (-0.235429, -0.165663) T-Test of mean difference = 0 (vs not = 0): T-Value = -11.41 P-Value = 0.000 Q: Has there been a significant decrease in the discrepancy rate for the 97 projects? A: Yes – the use of the Process Performance Program has been successful at reducing the discrepancy rate from a mean of 24.6% to 4.6%.
  5. 5. Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group.Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group. Process Performance Program Program Overview
  6. 6. Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group. 6 Six Sigma Disciplines ProcessStandardization ProcessDesign Process Improvement DMAIC Define–Measure–Analyze–Improve–Control LeanPrinciples DMADV Define–Measure–Analyze–Design-Validate
  7. 7. Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group. Project Model by DMAIC Phase Define ControlImproveAnalyzeMeasure Identify candidates Executive Introduction Scope Project Complete Charter Random Sample UHC analyzes data Provider analyzes data Compile Research Baseline Defect Rate Collaborative Defect Review & Root Cause Analysis Stratification & Statistical Analysis Define/ Measure/ Analyze Tollgate Improvement Plan Implemented Improve Tollgate Claims Rollout time: 6-8 weeks Final Defect Rate Control Plan & Scorecard Control Tollgate Random Sample UHC analyzes data Provider analyzes data Compile Research • A discrepancy is any time the UHC reimbursement does not match the Hospital or Medical Groups’ expectations
  8. 8. Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group. The Process Performance Program Project Life Cycle Project Cycle Time is between 6 – 8 months. Resource allocation intense during Planning Phase and 3 Day onsite meeting
  9. 9. Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group. Process Performance Model Roles & Responsibilities UHC Resources • Black Belt(s): Project lead/HP3 staff. • Master Black Belt: Assists Black Belt on an as needed basis with technical expertise. • Project Sponsor/Business Champion: Executive on point to guide team as needed • Hands-On Champion: Executive on point to guide team as needed. • Process Owner: Expert in knowing contract intent and translation, accountable for on-going provider relationship, aware of improvement opportunities/issues. • Data Miners: Claim research expert/HP3 staff. • Subject Matter Experts: Engaged as appropriate; Provider Resources • Black Belt(s): Project lead/Hospital Six Sigma program staff. • Master Black Belt: Hospital Six Sigma program staff. • Project Sponsor/Business Champion: Typically hospital CFO or COO. • Hands-On Champion: Typically VP of Managed Care/Patient Account Services. • Process Owner: Typically a Director or Manager of Hospital/Health System Billing. • Billing Coordinators: Billing research expert. • Subject Matter Experts: As appropriate; technology managers, notification staff, etc. Optional
  10. 10. Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group. Process Performance Program Kick Off Meeting The project kick-off meeting is the formal start of the project and should be attended by all project sponsors and stakeholders Key Points to be Covered: • Team Members & Roles • Project timeline & Tools • Meeting schedule for RDM Session Planning • Data Discussion Champion/Sponsor(s): Process Owner(s): Problem Statement: ABC HealthSystem averaged 3,106 (combines UNET, COSMOS, & FACETS) claims submitted per month to UnitedHealthcare from July 2008 through June 2009. A deep diveanalysis of 500 ABC’s claims with October 2009 dates of service found that xx.x%of the claims had discrepancies between the payment that ABC expected and the amount allowed / paid by UHC. Critical to Quality (CTQ): Matching ABC’s contractual expected amount and posted payments to UHC’s allowed amount for each claim. Defect: Discrepancies between ABC’s contractual expected amount and posted payment, and UHC’s allowed amount for each claim (includes UHC and patient’s liability). Lead Black Belt: Master Black Belt: Team Members: See Next Slide Process Name: ABC/UHC–Claim Adjudication andPayment; ABC– Bill Generation,Submission &Reconciliation Customer Impact: Improved claims processwill decreaserework for ABC and UHC. Customer satisfaction will improve with less claim discrepancies. Improved relationshipwithABC Project Scope/Boundaries In-Scope: Commercial physician servicesclaimscovered under the contract between ABC and UHCand billed on aHCFA 1500. Out-of-Scope: Medicare &Medicaid products,along with and all other services not covered under the contract between ABC and UHC Start / Stop: Patient service isscheduled / Account for service is zero-balanced by ABC Goal Statement: Reduce ABC /UHC payment discrepancies from xx.x%to ?5%by May 31, 2010 Phase Estimates 5/31/20105/1/2010Control 4/30/20102/16/2010Improve 3/19/201012/15/2009Analyze 3/19/201012/15/2009Measure 2/18/201012/15/2009Define Completion DateStart Date Lifecycle Phase 5/31/20105/1/2010Control 4/30/20102/16/2010Improve 3/19/201012/15/2009Analyze 3/19/201012/15/2009Measure 2/18/201012/15/2009Define Completion DateStart Date Lifecycle Phase =5%TBDDiscrepant Claims TargetCurrentProcess Metrics =5%TBDDiscrepant Claims TargetCurrentProcess Metrics The project charter & process maps are often introduced to the team at this point
  11. 11. Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group. Red = Location of root causes Sample Process Map & Root Cause Locations
  12. 12. Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group. Project Data Requirements • Discrepancy Definition: A discrepancy is any time the UHC reimbursement does not match the Hospital or Medical Groups’ expectations. • Data Population = 1-3 months of service dates (depending on monthly volume) • 300-500 random sample of claims extracted from population • A MSA tool is populated using random sample data. This tool is used by BOTH organizations to identify discrepancies within the sample prior to the onsite RDM.
  13. 13. Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group. Percent Count 60 Percent 45.8 22.6 8.3 7.3 4.6 3.2 2.2 1.9 693 4.0 Cum % 45.8 68.4 76.7 84.1 88.7 91.9 94.1 96.0 341 100.0 126 111 70 49 33 29 Other Detail H Detail G Detail F D etail E Detail D Detail C Detail B D etail A 1500 1200 900 600 300 0 100 80 60 40 20 0 Detailed Root Cause for Process A Discovering the Root Cause Drill down analysis of discrepancies is performed through the use of “5-Why’s” methodology to get to actionable root causes Count Percent Count 237 164 163 226 Percent 23.4 12.2 12.0 11.5 9.7 1512 9.7 5.6 3.8 3.7 2.5 2.5 3.5 Cum % 23.4 35.6 789 47.6 59.0 68.7 78.4 84.0 87.8 91.4 94.0 96.5 100.0 774 741 629 627 360 244 O ther Process I Process H Process G P rocess F System B Process E Process D System A Process C Process B Process A 7000 6000 5000 4000 3000 2000 1000 0 100 80 60 40 20 0 Discrepancies by Root Cause
  14. 14. Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group. Onsite Rapid Decision Making Session
  15. 15. Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group. Improve and Control Phases Re-Measure Analysis If.. Goal has been met, Then... • Finalize scorecard and control plan • Close out project Goal has NOT been met, Then... • Review discrepancies for root cause • Check for new solutions • Implement new solutions • Re-measure to check for improvements (Repeat improve & control phases) Statistical tests are performed to determine validity of project results.
  16. 16. Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group. 16 Control Plan and Scorecard Control Plan The Control Plan ensures that performance shifts from either entity are detected early Scorecard The scorecard indicates when engaging the response plan is appropriate As of Date Combined Scorecard Explanation of Variances and Control Plan Discrepancy Type 0 5 10 15 20 25 30 Type A Type B Type C Type D Type E Type FType G Type H Type I Type J Type K Type LType M Type N Type O Type PType Q O ther Number 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Cumulative% Discrepancy Type Trend 0 5 10 15 20 25 30 01/10 02/10 03/10 04/10 05/10 06/10 07/10 08/10 09/10 10/10 11/10 12/10 Discrepancy Rates 0% 2% 4% 6% 8% 10% 01/10 02/10 03/10 04/10 05/10 06/10 07/10 08/10 09/10 10/10 11/10 12/10 Percent USL Measurement Spec Limits Data Source Frequency Responsible Party Dala Collection Plan Response Plan Reference Docs Discrepancy Rate X% Discrepancy Report by cause code Monthly Owner A Run standard report monthly; submit data by 15th working day. Hold inter-company meeting to review descrepency data including type and trend. Develop related action plan to address specific causes. Scorecard Discrepancy A X% Monthly provider scorecard Monthly Owner A & B Run monthly provider scorecard. Submit data by 15th working day. Complete assessment of drivers of increased discrepancy rate. If special cause, ensure resolution of cause. If trend; assess contract terms for provisions resulting in manual adjudication. Work with provider to resolve. Scorecard Control Plan Process: Provider Payment Match Process Owners: Owner A and Owner B Review Process and Frequency: Monthly Scorecard Inter-Company review if discrepancies exceed xx% Previous State: Provider and UHC DMAIC project determined through a data sample that there was a xx% discrepancy rate as defined as actual payments versus expected payments. Key solutions were developed and piloted to correct the problems 1) Solution A 2) Solution B 3) Solution C To ensure that these solutions are finalized and remain intact to prevent return to the previous state, control measures and tools have been developed to assist process owners. Process Control requires regular monitoring of these measures through data collection and analysis. The suggested response plan is included but the Process Owners may add to these responses. Their critical function is to take action when measures indicate operational reporting is getting out of control. If there are any questions about this plan, please contact the Process Performance BB.
  17. 17. Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group. Collaboration is Imperative A combined process… produces discrepancies that are not recognizable when looking at the Hospital or Medical Group and payer systems independently A collaborative approach… enables the highest capability of discrepancy identification A common goal… to improve administrative simplification for both organizations by improving the collective and respective processes that contribute to 1st pass claims payment accuracy
  18. 18. Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group. This is Just the Beginning. . .

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