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Information Systems in Managed Health Care Plans


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Final Presentation for my Healthcare Reimbursement class

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Information Systems in Managed Health Care Plans

  1. 1. Information Systems inManaged Health Care Plans By: Jolly Pandyacc Anthony Harding Jitka Gruntova Tony Mbirwe
  2. 2. Content• I. Part: Introduction• II. Part: IT Function Overview• III. Part: Delivery Attributes of The IT System• IV. Part: Market Trends and IT• V. Part: Conclusion
  3. 3. Introduction••• Execution of Business and the customer experience are nearly entirely information technology driven• Technology enables everything from core processes, such as claims adjudication, to consumer touch points, such as, websites, and customer service systems, to internal enablers, such as, employee email and medical management enabled technology systems
  4. 4. What Technology Can Do• Information technology can help reduce errors in medications• Use of computerized physician order entry (CPOE) can reduce medication errors by 80%• (foundation for e-health)Picture archiving & communication system (PACS) eliminates need for films, allows interaction on a global scale: savings, improved quality & cost reductions• Improvements in diagnosis & treatments with technology help the quality & availability of care• Telemedicine/telehealth: monitoring chronic diseases over distances allows for access to care, quality of care, & reduces costs
  5. 5. To The Consumer Example-Young womanTo the consumer experiencing lower back pain 1. She visits her health plan website to research• Insurance is not a simple her symptoms and boor for a Doctor transfer of risk, but rather a 2. At the Doctor office she hands I.D card to the staff member at front desk who confirms series of interactions that are eligibility by using a interactive voice response system. all technology enabled 3. After visit the provider submits a claim via claims clearing house to the insurance company 4. Claims processing system adjudicates the claim according to the patients current benefit 5. Young woman receives explanation of benefits in mail but is concerned with error 6. She visits website to look for information related to claim and places to call customer Service 7. Customer Service call is routed to a customer service representative who then uses interface to health plan’s internal membership, claims, and benefits systems responding to the inquiry documenting the interactions with the member 8. Scenario represents the pervasive nature of Technology
  6. 6. Critical Internal Information Technology Function Overview• I.T department designs, implements, operates, and maintains systems that perform critical core business processes essential to day to day operation of the health plan organization• Must be completed efficiently and accurately on an ongoing basis, and new efficiencies must be created to achieve cost reduction opportunities• Storage system must be packed with a set of interfaces that allow other systems, such as claims and customer service applications to access this data for processing inquires
  7. 7. Products• Products are the entities that are sold by health plans and bought by consumers• 2 main consumers groups in the health insurance market-employers who offer it to employees and individuals who don’t receive it through employers• I.T must support the systems that manage the individual variables for each product• I.T solutions must facilitate the input and ultimately store benefit levels, procedures, code information, deductible amounts, co insurance or co pay amounts, and other data points that determine how members get paid
  8. 8. Eligibility• Moved to IVR phone system to Web • Tape-Tape data base transfers from based provider portals employer• The systems are queried by providers • Or Via a secure electronic to determine how a patient should be connection billed at the time of service • Advance health Plans offer• Eligibility systems are also involved in Automated tools to sales agents and determining how to bill the employer brokers like demographic or member information which is transmitted• Information is loaded when individual • Maintenance phase is when or group signs up then is put in information is updated eligibility system (older system is • I.T must support both the called legacy system.) enrollment, and maintenance process • Custom feeds must be designed from• Electronic loading-entering info on employer’s personnel system, and secure website and password protected Interfaces must be built by customer IVR system via secure web• Imaging is used strict security and privacy are used under HIPAA • Some large firms outsource but I.T still runs it
  9. 9. Claims processing• Provider network system or databases are queried to determine whether the provider or hospital billing for the services is part of any of the health’s plan’s network (HMO or PPO)• In network out of network claims• Authorization & precertification• HIPAA mandated standards for submission, query, and response• Lags behind even though physicians are starting to grow to more modern software• Paper fax & phone common use
  10. 10. Claims Submission to Health Plan• Electronic EDI=electronic data interchange reduces labor• Large Hospitals=claims clearing house which establishes electronic connections between Physicians hospitals, billing services, and health Plans• Moves claims and inquires electronically among the parties• Large Insurance companies have outsourced manual data checking, and entry to off shore locations
  11. 11. Medical Management and Predictive Modeling• All medical management activities are supported and enabled by I.T• Including Decision support systems, tracking and case management systems• Enabled patient centric devices and interfaces like a scale that sends congestive heart failure patients daily weight to the health plans disease management program• More Access better health management and better out comes keeping the cost low
  12. 12. I.T Responsibility to Plan• Creation of (PHR) Personal Health Record & more availability through system• Adopt EMR electronic medical record• Must maintain data warehouse, and use sophisticated data mining and informatics tools to transform the raw data into information for use by the medical management systems• Systems must be designed so that data gathered can be quickly and easily transformed into actionable information
  13. 13. I.T Support leading practices• Automated Creation Care Plans• Automated routing of new participants care plan to correct disease manager• Ability to view claim history, and EMR (Electronic Medical Record)• Customer Relations Management System• Quality Plus Program• NCQA Accreditation Review Process• PBX telephone system• (transactions & code sets• Electronic transactions
  14. 14. DocumentationRisk stratificationPredictive Modelingsoftware ranking levelsof severityEstablish outbound callfrequenciesPeriodic care call forprevention care
  15. 15. Provider Credentialing and Network Maintenance• Data feed provider directories printed and online used by consumers to make contacts• Provider Credentialing and Network Maintenance• Data feed provider directories printed and online used by consumers to make contacts• Credentialing program collects detailed information about the provider’s medical training, certifications, and any specialties disciplinary actions• National Practioner Data Bank is a requirement under credentialing• Maintenance of provider Database or file is function of Network management• I.T organization must design solutions and interfaces that can assist in the collection use, and maintenance of provider Data• Electronic communication
  16. 16. Challenges of I.TUse of imbedded intelligence to help drivereimbursement systemsHard coding of identifiersProvider ID field type cannot accommodate theformat of NPI
  17. 17. Member ServiceKey Market Differentiator for IVR Systems must integrate well withHealth Plan traditional services channels likePositive & negative experiences customer service, and trackingChallenge since call centers, and Tracking and reporting solutions mustWeb Portals is customer be deployed to identify issues and keyexpectations metrics for managementMembers demand accurate Sophisticated load balancing software to help calls move from location toinformation across multiple channels locationfor convenience Outbound calls to influence membersEmail & Web chat more Prominent behaviorSelf Service Channels such as online I.T must support member services bymember Portals integrating multiple technologies I.T must educate so service associates can educate members effectively
  18. 18. Consumerism and the Proactive Approach• Easy to use decision support system enables the front line to assist members in their treatment choices• Robust customer insights and analytics tools• Enabling the identification and segmentation of member populations for targeted interventions• Enabling view of PHR
  19. 19. Information Systems in Managed Health Care Plans Employer I.T Provider I.T Portals can enable Provides method to verify enrollment and maintenance patient eligibility capabilities Web Portals to submit Employers can edit claims or reconcile employee eligibility receivables against View and Pay bills online payments Enable features for employees to complete initial enrollment online
  20. 20. Information Systems in Managed Health Care Plans Bookers and I.T agents Member Provide tools and Provides a way to deliver self-service capabilities to existing customers, and information to assist in the a way to deliver product information sales cycle and decision support tools to potential customers I.T must support E-Business initiatives by ensuring web based solutions are complementary to other channels Must be in place to monitor and correct system issues outside of business hours
  21. 21. Internal EnablersI.T organization is to manage, maintain, and serviceenabling capabilities such as email, telephone, andother communication channels for health planemployees
  22. 22. Borrowing TechnologyTechnology from the financial service industry plays role inpayment of healthcareSwipes Cards-is easy access to spending account funds &relief in Account ReceivablesUse of Card to verify eligibility & Co paySmart cards do the same thing but it holds limited personalhealth record informationProviders receive timely & accurate information thatminimize bad debtNo paper work for consumer filing
  23. 23. Healthcare Integrity• HIPDB- fraud Program and fraud tracking system• HIPAA- mandate standards for electronic transactions became effective in May 2002 (May 2003 for small health plans)• Privacy regulations became effective in April 2003 (2004 for small health Plans)• National Provider Identifier-May 23 2007• Additional measures for electronic PHI (protected health information that is maintained in electronic media which includes hard drives, computer disk, internet, and email
  24. 24. Security Standards Applicable to electronic protected Health Security management process  Facility Access controls Assigned security  Workstation use responsibility  Workstation security Workforce Security  Device and media controls Information access  Access control management  Audit Controls Security Awareness  Integrity Security Incident procedures  Person or identity Contingency Plan Authentication Evaluation  Transmission security Business associate contracts
  25. 25. Delivery Attributes of the IT SystemsThe Nationwide Health Information Network governance expects entities thatparticipate in the Nationwide Health Information Network to include elements of:• privacy and security• usability• flexibility (interoperability)
  26. 26. 1) Security and Privacy• In order for providers and patients to have trust in health IT and information exchange, they must be confident that privacy and security laws are in place and will be enforced.• Federal laws and regulations such as HIPAA and the Sarbanes-Oxley Act, as well as state laws and regulations in some cases, mandate additional constraints on technology and processes to ensure the security and privacy of consumers
  27. 27. Statutes and RegulationsStatutesAmerican Recovery and Reinvestment Act of 2009 (ARRA)This statute includes the Health Information Technology for Economic and Clinical Health Act (theHITECH Act) which establishes the Medicare and Medicaid EHR Incentive Programs that encouragemeaningful use of certified EHRs and other health information technology (IT) to improve quality ofcare.Health Information Technology for Economic and Clinical Health Act of2009 (The HITECH Act)The Health Information Technology for Economic and Clinical Health (HITECH) Act, passed as partof the American Recovery and Reinvestment Act of 2009, allocated billions of dollars for the healthcare system to adopt and meaningfully use health IT to improve health. A number of provisions in theHITECH Act strengthen the privacy and security protections for health information established underthe Health Insurance Portability and Accountability Act of 1996 (HIPAA).Health Insurance Portability and Accountability Act of 1996 (HIPAA)HIPAA called for the establishment of standards and requirements for transmitting certain healthinformation to improve the efficiency and effectiveness of the health care system while protectingpatient privacy.
  28. 28. Statutes and RegulationsRegulationsMedicare and Medicaid Programs: Electronic Health Record IncentivePrograms Final RuleThis rule specifies the initial criteria that eligible providers must meet to qualify for the Medicare andMedicaid EHR incentive payments, and it includes other incentive programs participation requirements.Health Information Technology: Initial Set of Standards, ImplementationSpecifications, and Certification Criteria for Electronic Health RecordTechnology Interim Final and Final RulesUnder these rules, the Secretary has adopted the initial set of standards, implementation specifications andcertification criteria that are required for the certification of EHR technology.Establishment of the Temporary Certification Program for HealthInformation Technology Final RuleThis final rule establishes a temporary certification program for the purposes of testing and certifyinghealth IT, thereby ensuring the availability of Certified EHR Technology for eligible health care providersseeking incentive payments available under the Medicare and Medicaid EHR Incentive Programs.
  29. 29. Statutes and RegulationsRegulationsEstablishment of the Permanent Certification Program for HealthInformation Technology Final RuleThis final rule establishes a permanent certification program for the purpose of certifying health IT.Breach Notification for Unsecured Protected Health Information InterimFinal RuleThis rule implemented section 13402 of the HITECH Act by requiring HIPAA covered entities toprovide notification following a breach of unsecured protected health information to individuals, HHS,and in some cases the media. This rule also requires business associates to notify covered entitiesfollowing a breach of unsecured protected health information.
  30. 30. HIT Standards and HIT Policy Committees Information Flow
  31. 31. 3) Usability• In delivering technology solutions, the IT organization must be aware of the ultimate use of the system; in other words: How will the system be accessed? What are the characteristics of the users?• Increasing the engagement and understanding of patients and providers may increase their willingness to participate in information sharing that they trust and that is private and secure, including secondary uses of EHR data in research.
  32. 32. 4) Flexibility• The first priority of health IT is to enable primary care physicians and specialist to electronically exchange lab results, patient care summaries, and medication histories• Health IT is also a critical tool in empowering patients. Existing and emerging technologies allow data to flow directly to and from the individual, wherever the individual may be. As a result, patient interactions with the health care system are no longer confined by the walls of the clinical setting and may occur frequently in between visits.• Personal Health Records (PHRs) allow patients to capture their own health observations. For example, mobile phones with glucometers allow individuals to track their blood sugar levels through their mobile devices. Mobile phones and related applications are being used in mental health to track moods and provide therapeutic interventions with personalized messages, exercises, and coaching. Using these tools, individuals can become more attuned to healthy behaviors, monitor their health, make informed personal health decisions, and receive preventative care.
  33. 33. MARKET TRENDS AND INFORMATION TECHNOLOGY (IT) The market research report analyses the key trends in global healthcare information technology market, and segments it into various submarkets as per their sizes in various geographies The global healthcare information technology market is estimated to be $53.8 billion in 2014The market is expected to grow at a high CAGR of 16.1% (from 2009 to 2014) because of government initiatives to reduce healthcare costs and the tremendous demand for healthcare IT applications such as electronic medical records Information technology offers solutions for almost all the areas in the healthcare system, including clinical trial management and clinical decision support Hospitals are also increasingly implementing e-prescribing systems
  34. 34. Consumerism• Today’s healthcare consumers demand more information about their healthcare providers in order to get quality services• This has led to more need for IT to collect and disseminate data• Data collected must be in compliance with, links to state records, consumer feedback• The system built must be flexible enough to accommodate structured and unstructured data.• IT must also support the consumerism movement by identifying ways to educate members on their own health – primarily through online tools and information – and supporting innovative product designs that incorporate new financial instruments and benefit designs• Health plans must justify the theory of consumerism to employer groups by reporting on the success of consumerism products. Data are required to illustrate that when more responsibility is transferred to consumers, they use health care services more intelligently
  35. 35. Pay-for-Performance• Due to increased focus on healthcare costs, health plans are developing new ways to pay providers for services rendered such as: -The pay-for-performance model- compensation is tied to compliance with best practices and results achieved, not just on the number or duration of services• IT must support this model by crating solutions that can collect these data from different sources, transform and load data into a storage area, and provide access methods for reporting systems and consumers
  36. 36. Plan as Financial Institution• The health insurance industry has often looked to the financial service industry as a role model in the evolution of the technology organization.• This helps evaluate risk and security involved while providing care• Consumers often bring expectations from other industries, such as financial services. Financial services are a decade ahead of the health plan industry in terms of delivering high-quality self-service capability to consumers.• For example financial institutions introduced self-service Web sites and automatic teller machines (ATMs) in the late 1980s and have quickly evolved those offerings based on consumer demands and feedback.
  37. 37. Conclusion• Evolving Information Systems of upcoming times is not so much about delivering bits and bytes, but ―supposedly‖ rather about delivering information, solutions (not creating problems!), and services to support managed care organizations.• Physicians and those doctors who are not very familiar with the electronic based information systems is going to face a major challenge since they will be at the bottom of the learning curve• Either it can increase the efficiency and functionality of the healthcare system or it can affect the quality of patient care where doctors/physicians are spending more time on computer than patients and their problems.
  38. 38. Conclusion - Where We Are Today• Only 15% of hospitals have some form of computerized medication order entry implemented. In those hospitals, physicians enter less than 25% of the orders• Only 10% of hospitals utilize bar-coded medication administration at bedside. Fewer than 5% of providers use computerized patient records• About 80% of the estimated 35 billion health transactions each year are conducted by phone, fax, or mail—not via the Internet. The financial services industry spends about 8-10% on information technology; HE healthcare industry = 2-3%• In 2010 only 25% of physician offices and 15% of acute care hospitals take advantage of EHRs. Even fewer use remote monitoring and telehealth technologies.• While many consumers access their banking information online daily less than 10% use the web to access their personal health information.•
  39. 39. Questions??• Do you anticipate betterment in efficiency and functionality of current managed healthcare organizations?• Will it overcome setbacks and provide more efficiency than current information systems?• Where do you see Information Systems in upcoming 3-5 years?
  40. 40. Resources• Geisler, E. (2008). The Role of Technology in Healthcare Delivery. Retrieved form technology.pdf• Kongstvedt, P., R. (2007). Essentials of Managed Health Care. Sundbury, Massachusetts: Jones & Bartlett Learning.•