Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Business Impact Presentation

367 views

Published on

  • Be the first to comment

  • Be the first to like this

Business Impact Presentation

  1. 1. Portfolio Management Business Impact Assessment Autonomic Nervous System Testing Business Impact Assessment Proposal Type: Full Scale Date: 06/25/2014 Project Sponsors: David Finley, MD Business Lead: Dr. Julie Kessel Presenter: Robb Coutinho BPMS ID: 13049 Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2014 Cigna 1
  2. 2. Overview/Background Information • Autonomic nervous system (ANS) testing is performed on individuals with specific symptoms to help diagnose & manage autonomic nervous system dysfunction. CPU will develop and post a coverage policy and implement CPT codes 95921, 95922, 95923, 95924, 95943 using a PXDX edit. ANS testing will be COVERED for specific medically necessary diagnosis codes and DENIED as EIU for all other codes. • These tests are PROVEN useful to diagnose some conditions; and is UNPROVEN for other diagnoses. In many conditions testing is not clinically useful. • Estimated Annual Total Medical Cost Savings: $2.4M • Estimated Annual Service Denials: 17,870 • Estimated Average Cost per Service: $143 • Medical necessity appeal rights will be issued • Competitive Landscape: All competitors who have policies agree. Neurological societies agree: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2014 Cigna 2
  3. 3. Idea/Concept Name Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2014 Cigna 3 • The CPU seeks to develop a medical coverage policy for Autonomic Nervous System Testing. This initiative seeks deny CPT codes 95921, 95922, 92923, 95924 and 95943 in ClaimsXten via a dictionary update to the MP_PXDX_PROF rule. WHAT • Target Date: 02/16/2015 • Neurologists, Cardiologists, Internal Medicine, Pediatricians • No Vendor Impacts • These tests are PROVEN useful to diagnose some conditions; and UNPROVEN for other diagnoses. In many conditions testing is not clinically useful. • Estimated Annual TMC = $2.4M WHY WHEN WHO HOW • Implementation Lever: Dictionary update to the MP_PXDX_PROF rule using ClaimsXten.
  4. 4. Autonomic Nervous System Testing Annualized TMC = $2.4M Unit cost per denied claim = $143 # claims to be denied = 17,870 1,249 unique HCPs denied 88% par utilization 8,876 Unique customers denied Codes 95921: Cardiovagal function testing 95922: Vasomotor function testing 95923: Sudomotor function testing 95924: Autonomic function, combined testing, with passive tilt 95943: Simultaneous function testing, head-up posture Vendor No Vendor Impacts Specialties impacted Neurologists, Cardiologists, Internal Medicine, Pediatricians Annualized Impacts What is Autonomic Nervous System (ANS) Testing? • The autonomic nervous system controls how our organs work. • Autonomic nervous system testing is performed on individuals with specific signs and symptoms to help diagnose & manage autonomic nervous system dysfunction. • These tests are PROVEN useful to diagnose some conditions; and is UNPROVEN for other diagnoses. In many conditions testing is not clinically useful. What is happening now? • Coverage policy is under development. • The CPT codes are not implemented and pay for all conditions without review. What is changing? • CPU will develop and post a coverage policy and implement the codes using a PXDX edit. • Autonomic nervous system testing (95921, 95922, 95923, 95924, 95943) will be COVERED for specific diagnosis codes listed a medically necessary and DENIED as EIU for all other diagnosis codes. • Medical necessity appeal rights will be maintained. American Academy of Neurology American Association of Neuromuscular and Electrodiagnostic Medicine Aetna, AmeriHealth Caritas (Medicaid) Anthem, Blue Cross Blue Shield Mississippi, First Coast Service Options (CMS Regional Carrier) None found
  5. 5. Scope  PHS and PHS+  Impacted claim platforms in scope: PMHS, Proclaim, Facets  Impacted Product Families? Medical  Impacted Product Types: PPO, OAP, Select, Managed Care (all products)  Impacted Market Segments: Select, Regional and National  Applicable to all states? All States  A national provider contract: N/A  Neurologists, Cardiologists, Internal Medicine, Pediatricians  Non-par providers  Communications: Date for sending: 11/15/2014; 1,109 HCP letters (Figure includes Top 10 Non-Par HCPs)  TPVs: Out of scope  CGHB: Out of scope  ID card changes: No ID cards will be reissued  On-Line or Paper HCP Directory Updates Needed: No  CareAllies: Out of Scope  Behavioral: Out of Scope  UB-04: Out of Scope Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2014 Cigna 5
  6. 6. Claim-Customer-HCP Volumes 6 Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2014 Cigna Claims Volumes Number of Claims/Services 17,870 Number/% Par 88% Number/% Non-Par 12% Number of Denied Claims/Services Avg. Cost of Service $143 Estimated Appeal Volume (Based on previous or similar experience) 894 (5% appeal rate assumption) HealthCare Professionals (HCPs) Number/% Par 1,099 Number/% Non-Par 150 Number of HCPs broken down by Provider Type (FA, AN, PR, AS) N/A Number of Letters to HCPs* (if applicable)/Target mailing date? 1,109* (11/15/2014) *Figure includes Top 10 Non- Par HCPs **If HCP letters are required will they just be sent to impacted HCP’s or a broader group of HCP’s? Customers Unique # of Impacted Customers* 8,876 Number of Letters to Customers* (if applicable)/Target mailing date? N/A *i.e. Customer disruption due to network change *Indicate how this number was determined: i.e. expected based on current claims, over the lifetime of initiative, based on next year's assumptions, etc.
  7. 7. Cost Benefit Analysis Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2014 Cigna 7 Question Answer and Additional Clarification What are the proposed savings? Estimated TMC savings of $2.4M Cigna Earnings Impact of $360K What are the assumptions used for the development of savings? Estimated annual denials = 17,870 Average cost = $143 Denial Volume Breakdown: (17,870) Proclaim: 14,653 PMHS: 1,787 Facets: 1,430 Are there any cost assumptions? Will need cost estimates from the following: Service Operations (Call, Claim, Appeal, CA/CAT) PBAB Sales Effectiveness HCP Communications Prepay Medical Management Has Medical Economics signed off on benefits? Yes
  8. 8. High Level Implementation Plan/Program Components Ensure Coverage Policy Updates Have Sign-off with Matrix Partners • Work with Prepay to complete the Intake form, query development, testing, and approval so claims can be ‘batched’ and sent to Medical Director for review • Work with Medical Management & Prepay to update Medical Necessity Denial letters if applicable. • Work with Legal and Compliance to ensure any state exceptions are properly implemented Provide Coverage Policy Coding Changes • The Coverage Policy Unit will develop the Autonomic Nervous System Testing coverage policy • Provide updated coverage policy coding to Implementation Team • The Change Request Authorizations will have to be supplied to McKesson by January 1, 2015 for the updates to take effect in ClaimsXten on February 16, 2015 release date • Implementation Leads will ensure information is coded into the system accurately. Update Standard Operating Procedures and Talking Points and Training • Notify CSAs and Appeals/Claim Processors that Cigna will be enforcing this policy • Provide the necessary information for Service Operations to update any talking points, scripts, and standard operating procedures (if needed) Develop a Communication Plan • Develop an external communication for customers and HCPs • Develop an internal communication for sales team and call center representatives • Assuming a 90-Day Notification period before policy goes live 8Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2013 Cigna
  9. 9. Customer Experience Impact 9Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2014 Cigna Question Answer/Additional Clarification Will this initiative increase Dr./Hospital/Clinic/Pharmacy choices, reduce it or have no effect? No Impact Will customers have to change Dr./Hospital/Clinic/Pharmacy as a result of this initiative? If yes, please explain. No Impact Will customers be denied claims that were previously accepted? If yes, please explain. Yes. Customers could see claim denials for Autonomic Nervous System Testing (CPT codes 95921, 95922, 92923, 95924 and 95943) Will customers see any reduced or increased out of pocket costs? Yes, a potential for increased out of pocket costs if non-participating HCPs are utilized. When and how will customers become aware of any changes to their coverage? No coverage changes. Will this create a negative customer experience? Yes Note: Annualized estimated impact = 8K customers Will this have a significant impact (positive or negative) on customer loyalty (i.e. likelihood of the customer to recommend Cigna)? TBD If a vendor is involved what will the vendor’s responsibilities include? No Vendor Impacts 1. Will the vendor outreach directly to the customer (email, letters, phone, etc.)? N/A 2. Will that outreach look and feel like it’s coming from Cigna or the vendor? N/A 3. Will the customer outreach directly to the vendor (phone, web, etc.)? N/A 4. Will the vendor act and feel like Cigna? N/A 5. If the customer calls Cigna but should have called the vendor, will the N/A
  10. 10. Sales / Client Experience Impact Question Answer/Additional Clarification # of impacted Clients & # of Claims including Customer & dollar impact) (Sales to determine criteria as to when a Client list is required, may include at least a 12 month look back ) 1,911 Client/Sales risks or impacts to Customers? Balance billing from Non-Participating HCPs Will this create a negative client experience? Yes Will letters need to be sent to Clients? If yes, who will receive letters, when, and the volume? None are planned as part of the project proposal When creating new programs/pilots, would the client be able to “opt out” of the program or pilot? If so, who would be responsible for that opt out process and what criteria will Sales need to submit? Where will the opt out information be stored and accessed by internal partners (e.g. Benefit Access)? Exception requests will be considered on a one by one basis. Market Segment Specific impacts? All Segments Vertical impacts? (Hospital, Government & Education verticals) Could this project impact the special vertical needs of each of those markets. N/A Impacts to SBCs (summary of benefits & coverage), SPDs (summary plan descriptions) and Benefit Summaries? N/A What’s the TMC, ROI, What is the ROI for the client and is there a need for a Sales Talking Points ? cost or outcome driving the need for this change to Sales? The CPU will partner with Sales Effectiveness to provide talking points Is there a cost that will be charged to the Client? Will the client see new Banking info, line items? (e.g. billed charge; bank charge) If yes, what is the benefit the Client can expect? Why is this change needed? (Client return) N/A Impacts to Contracts or ASO agreements? N/A Can this proposal be incorporated into on-renewal experience? If not, why? N/A Reporting Needs - Who will own reporting? Who would own report requests? Medical Economics will track ROI If it’s a new plan or plan based change when are new plans effective? When are enrollments slated to occur? N/A 10Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2014 Cigna
  11. 11. Other potential topics to include See the pre-IA Questionnaire at end of this presentation for a complete listing of potential impacts 11Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2014 Cigna Question Answer/Additional Clarification Impact to Product team? Can Product support the request? No Impact If vendor is involved provide contract progress to date, vendor responsibilities, contractor, etc. and has a contract been signed? If not, is there a letter of intent? N/A Are there any online services required? N/A Are specific Cigna coverage policies impacted? If so, what are they? Does the Cigna policy support the actions of the vendor? If not, is a reconciliation underway that includes Dx and Px codes? The Coverage Policy Unit will develop a coverage policy for Autonomic Nervous System Testing Are there regulatory and compliances issues identified for the specific states or accrediting organizations? Compliance considerations are under review (Emily Pickering) Will the change impact any claim processes If so, how? N/A Are there current and/or requested prepay edits/processes or macros impacted? If so, provide example/detail. No Will the change impact the pre-cert process? If so, how? N/A What types of non-standard requests could be anticipated with the result of the project or process improvement implementation? How many? TBD When creating new programs/pilots, would the client be able to “opt out” of the program or pilot? If so, who would be responsible for that opt out process and what criteria will Sales need to opt out of a program/pilot? N/A
  12. 12. Links  BPMS 13049  IA Working Folder  Autonomic Nervous System Testing Client/HCP Detail  IA Response Form  Kickoff & Deep Dive meeting minutes Meeting minutes  Supporting Documentation:  IT/BA Enterprise Architecture Guidance (if applicable) 12Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2014 Cigna
  13. 13. Offered by: Connecticut General Life Insurance Company or Cigna Health and Life Insurance Company. "Cigna," and the "Tree of Life" logo and "GO YOU" are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. All models are used for illustrative purposes only. 864805 05/13 © 2013 Cigna. Some content provided under license.

×