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

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