Key Issues in Healthcare Coverage
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The document discusses key issues in health care including payment integrity, utilization management, and provider management. It provides details on Dell Healthcare Services' approach to these areas. For payment integrity, it describes challenges payers face and typical fraud, waste and abuse cases. It also outlines Dell's suite of payment integrity solutions. For utilization management, it discusses clinical review services, the review process, and benefits of Dell's approach. For provider management, it gives a simplified view of the provider data management flow and importance of having a single source of truth for provider data.
Key Issues in Healthcare Coverage
- 1. Key Issues in Health Care Coverage Dell Healthcare Services POV: • Payment Integrity • Utilization Management • Provider Management
- 2. 2 Dell - Internal Use - Confidential Introduction to Dell Services 52,000+ team 90+ countries 60 tech support centers 10 solution centers Applications Services Business Process Services Business Consulting IT Consulting Infrastructure Managed Services Cloud Services Configuration & Deployment Support Services Applications Business Process Consulting Infrastructure Support Strategic AlliancesAcquisitions 5 global command centers
- 3. Agenda • Payment Integrity • Utilization Management • Provider Management
- 5. 5 Dell - Internal Use - Confidential Key challenges for the healthcare industry Actionable recovery- oriented results stem the tide of bad behavior Very few solutions exist with a national footprint able to apply state-specific results Fraud schemes take hold before applicable corrections exist, costing millions of dollars Sophisticated fraud and abuse schemes are a major problem A less than holistic approach encourages abuse
- 6. 6 Dell - Internal Use - Confidential Typical FWA cases encountered Mismatch between medical records and claims data Phantom bills and charges Exploitation of benefit plans Billing for services never rendered or up-coding for services Unnecessary diagnostic services or medically unnecessary services Diagnostic code manipulation Medical identity theft Frequency of visits Billing inpatient when service can be done in an outpatient setting Unusually high HCC scores
- 7. 7 Dell - Internal Use - Confidential Address key challenges with a complete suite of payment integrity solutions • Advanced integration of best practices and strategic partnerships provide comprehensive FWA detection and management, and facilitate improved efficiencies • Industry-leading automated claims evaluator for complimentary claims analysis • Cross-partner and enterprise integration and analysis is recommended to identify, validate and manage FWA • Expert clinicians and advanced ICD-10 tools investigate and perform medical necessity and utilization reviews • Analysis of suspicious incidents across disparate processes and systems • Manage FWA with scores generated with advanced analytics service • Suspect cases coming from claims and customer service queues Investigation Medical review Data analytics Revenue Management Core Components • Advanced analytics to improve audit & recovery results • Implement best practices across Medicare, Medicaid, and commercial clients • Experienced pool of RNs, coders, clinicians, pharmacists, statisticians, & data analysts FWA Services Coordination of Benefits Subrogation 3rd Party Recovery UM Services Consulting & Integration
- 8. 8 Dell - Internal Use - Confidential High level lifecycle of FWA management Claims Source from Payer (Medical & Pharmacy) Clean Claims Pre-payment Detection Retrospective Detection FWA Application Scores for Suspected FWA Cases Validation Services Categorization of Reason Codes Investigation and Recommendation Request More Info Recommend for Denial Recommend Education Recommend Payment Scoring Engine Application with HMS Special Investigation Unit (SIU) of Payer Feedback Loop Dell BPO Services using the DBPMS* Workflow Tool Feedback Loop
- 9. 9 Dell - Internal Use - Confidential Search for a single source for full spectrum claims integrity Financial Accuracy ServicesClinical Accuracy Services Complex Clinical Reviews • Place of service • Utilization review • Specialty audits • Coding validation • Clinical validation • Medical review Data Mining • System, policy & contract compliance Coordination of Benefits • Data matching and recovery • Eligibility verification • Identification Fraud, Waste & Abuse • Investigations Subrogation Workers’ Compensation Premium Protection Credit Balance Claim Stages Pre-payment | Post-payment Claim Types Hospital | Facility | Physician/Provider | Pharmacy | Ancillary Error Types Eligibility | Financial | Clinical | Compliance | Fraud LOBs Commercial | Medicare | Medicaid | Duals
- 10. 10 Dell - Internal Use - Confidential Considerations for a broad spectrum program Pre-payment: Checks of the clinical record before a payment is made are becoming more possible and imperative Federal edits aren’t enough: Edits and algorithms, including forensic coding customized to federal & state regulations & plan-specific policies, should be a standard expectation Review of more esoteric services: Catches bad actors hiding in the shadows Investigative support: Ensures quality of findings and recoveries Under one roof: Means cohesion of communication and results 1 2 3 4 5
- 11. 11 Dell - Internal Use - Confidential Coordination of benefits Data from 1,500+ insurers Claim billed to correct partyCarrier Member Provider Health plan Claim and member data Claim Payment Proprietary processes Key Payer Issues: Unnecessary Overpayments Industry data indicates that other insurers should cover .5% to 1.5% of all paid claims Administrative Challenges Costly and error-prone manual processes Multiple claim touches Phone calls to policyholders Extensive annual surveys Value to be gained through improved processes Industry data projects the potential for $0.25 per policyholder per month For 100,000 members this would equate to $25,000 in administrative savings per month
- 12. 12 Dell - Internal Use - Confidential Subrogation
- 14. 14 Dell - Internal Use - Confidential Clinical review services • Prospective (prior auth), concurrent & retrospective reviews • DRG validation, quality of care, bill audits • URAC accredited • Quality peer review • External reviews/ACA • Third-level appeals from insurance departments • URAC accredited • Community-based behavioral health & waiver services • Medical necessity, staff qualifications, documentation & billing • Onsite & desk audits (complex) Independent Review Provider Audits Utilization Management
- 15. 15 Dell - Internal Use - Confidential Clinical review process Chart / Request Intake • Project Specialists • Imaging Systems Initial Review • Registered Nurses • Behavioral Health Clinicians • UR Review Platform Initial Physician Review • Staff Physicians (IM, GP, FP, Surgeon) • Contracted Physician Reviewers Reconsideration w/2nd Level Physician • Specialty Matched Physician • Physician-to- Physician Consult Appeal • Medical Director • Clinical Director • Legal Care Guidelines Providing much more than authorization criteria, the evidence-based clinical guidelines which are used drive high-quality care through tools such as care pathway tables, flagged quality measures and integrated medical evidence
- 16. 16 Dell - Internal Use - Confidential Utilization management overview Offer flexibility to customize group- specific business rules Experienced staff: • UM nurses must have active licensure in state of practice; diverse medical backgrounds; at least 5 years of clinical experience • Review to see if nurses have 4-year degrees, prior call center experience, and/or medical coding/terminology knowledge Urgent call center is available around-the- clock for weekend and emergency pre- certifications and appeals Standard UM call center is open 8:00 am–8:00 pm ET, Monday–Friday Automated system triggers identify members who may benefit from case management intervention; supports quality of care & cost containment
- 17. 17 Dell - Internal Use - Confidential New to market: Healthcare Information Security Program Auditor Referral Sources Automated triggers are built to identify UM cases that will benefit from Case Management By identifying high-risk cases through precertification, can begin to actively manage members earlier, which greatly increases the opportunity for cost savings Allows for early intervention that supports quality of care and cost containment Examples of cases to be referred from can UM include: • High-cost, high-acuity ICD-9 diagnosis codes and CPT codes • Hospital length of stay of five days or more • Previous CM activity/referrals • Two or more events in previous 180 days
- 18. 18 Dell - Internal Use - Confidential Utilization management process flow Toll-free call is received from the provider or member for precertification. Call is screened and patient information is obtained by Intake Coordinator. Medical necessity criteria is met: Services/admission certified, length of stay assigned, authorization letters sent within 1 business day. Medical necessity criteria is not met: Case sent to physician for medical necessity determination. Physician determines medical necessity. Approved: Length of stay assigned, requestor notified within one business day, authorization letters sent. Not Approved: Noncertification letters sent, provider and attending MD notified and informed of appeal rights. Criteria is applied. Medical necessity determination is made. Plan of care and reason for admission obtained. If the information is incomplete, Calls made to provider to obtain additional information.
- 19. 19 Dell - Internal Use - Confidential Utilization management benefits Cultural & Operational Fit • Vendor should have a strong cultural understanding of its customer’s operating environment Engagement Model • BPO engagement model provides flexibility at lower costs • Managed engagement model ensures outcome-based relationship Leadership in UM Services • Does it have leadership in UM services, with experience in state, federal, and health plan- specific requirements? Accreditation • Must have URAC accreditation for UM and independent review services Lower Startup Costs • Vendor should invest in setting up and training a team on health plan-specific processes Flexible Capacity • Vendor should offer flexible options to ramp-up/ ramp- down that can help health plans manage inventory during peaks and valleys of membership growth Continuous Process Improvement • Does it have time and logistical experience in developing and using BPO=- specific tools to optimize processes for continuous improvement? Cost Containment Analytics • Does it provide, at a minimum, quarterly statistical reporting of PA/UM results with cost containment recommendations?
- 21. 21 Dell - Internal Use - Confidential Simplified view of provider management flow 21
- 22. 22 Dell - Internal Use - Confidential Provider Contract Data Contract Data Uses: • Credentialing • Directories • Reporting • Claims adjudication • Provider payments Contract Data Includes: • Demographics • Fee schedules • Discounts & payment exceptions • Provider groups • Other contract- based information Aligning fee schedules with providers and provider types Inputting provider contract data into health plan’s database for downstream uses Inputting provider demographic updates Alignment with health plan’s credentialing department Adding/deleting providers w/groups and affiliations Doesn’t include: • Provider outreach for contracting or updated information/demographics • Review contract for accuracy/corrections • Provider follow-up
- 23. 23 Dell - Internal Use - Confidential Using a NCQA end-to-end credentialing organization *Primary source verification Easy to use for input & mgmt. of provider data & support docs Smart Web Portal Multiple Users & Customers • Hospitals • Commercial health plans • CAQH • State Medicaid Agencies • MA health plans • Other licensure orgs. CVO Internal Engine • Application packet • State licensure • CDS • DEA • OIG • Board cert. • Background check • Many Others Application printed, mailed, collected, scanned, w/3x follow-up Mail & Collect Electronically retrieve applications directly from CAQH’s ProView CAQH Multiple input sources to cover all bases and options; greater flexibility; highly customizable Inputs Performance guarantees; costs reduced by 20-40%; speed verifications by 30-60% PSV* resources Screen providers for cred/recred & demographic changes; fed & state sanctions; maintain nat’l certs. Monitoring
- 24. 24 Dell - Internal Use - Confidential Why must you have single source of truth for provider data? Includes which providers are accepting new patients, locations, contact information, specialty, medical group, & any institutional affiliation; directories must be easily accessible to plan enrollees, prospective enrollees, the State, FFM, state exchanges, HHS, & OPM *paraphrased from 45 C.F.R. 156.230(b) 2.4% of all providers change addresses or other contact information every month 5% change their license status every year 30% change their hospital or practice-group affiliations every year 20% of claims fall out of auto- adjudication due to provider data issues; adds ~$8-15 per affected claim 35% of provider listings contain errors; 32% of listings are duplicates; false provider information is billing fraud Paying sanctioned providers triggers CMS fines; incorrect 1099’s triggers IRS fines; Up-to-date: at least monthly & easily accessible when general public is able to view all current providers for a plan in the directory on the issuer’s website through a clearly identifiable link/tab without having to create/access an account or enter a policy number The public should be able to easily discern (1) which providers participate in which plans & provider networks, & (2) if the issuer maintains multiple provider networks, to see the plans & networks associated with each provider, including the tier in which the provider is included* Effective 1/1/16, exchange & Medicare Advantage plans: Must publish an up-to-date, accurate, & complete provider directory ≤$25,000 per beneficiary for Medicare Advantage; ≤$100 per beneficiary for FFM
- 25. Thank you For more information: Visit Dell.com/HealthPlans David M. Buchanan, JD | 601-259-7579 | David_Buchanan@Dell.com Jody Miller | 913-901-7290 | Jody_Miller@Dell.com