Operationalizing Requirements for Your Managed Risk Population: Achieving Accuracy and Compliance...
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Transcript of Operationalizing Requirements for Your Managed Risk Population: Achieving Accuracy and Compliance...
Operationalizing Requirements for Your Managed Risk Population: Achieving Accuracy and Compliance through use of Optum Technology Solutions
Presented by:
Margaret Golden, OptumInsightLisa Jaramillo, OptumInsightRolf Williams, Brown & Toland Medical GroupLinda Martinez, Brown & Toland Medical Group
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Disclaimer:The content of this presentation represents the views of the author and presenters.
GE, the GE Monogram, Centricity and Imagination at Work are trademarks of General Electric Company.
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Agenda
• GE Healthcare/ OptumInsight Partnership
• Introduction to Optum’s FRM Solutions
• Brown & Toland Medical Group Business Overview
• Optum Medicare Advantage Inpatient Accumulators
• Questions
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
GE Healthcare/OptumInsight Partnership
Global Works Systems Founded 1992
Professional Services Practice 1995
Software Solutions Introduced 1996
Communication Manager (FLS) for Managed Care developed 1999
Communication Manager Scheduling module developed 2003
Communication Manager BAR module developed 2006
GE partnership established 2006 – 2007
Global Works acquired by Ingenix (now Optum) 2008
GE partnership expanded to include software reseller agreement 2009
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
OptumInsight Solutions For GE Centricity Business
• Communication Manager
– Financial Risk Manager– Patient Access – Revenue Cycle
• Statement Manager
• Physician Schedule Manager (One Look)
• Security Manager
• Integration and Data Extraction Tools
• Technical Services
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Communication Manager
• Enables organization to produce Forms and Letters• Uses data stored in GE Centricity Business modules• Automates workflows• Provides flexible letter creation and production• Robust formatting and rich graphic capabilities using Microsoft® Word
• Ability to reduce expenses through streamlined communications
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Financial Risk Manager Letters
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Compliance
• CMS and payor requirements
– Language
– Fonts and formats
• Audit trail of all correspondence– Letter stored in history exactly as sent– View and reprint
• Multiple recipient copies– Appropriate content for members, physicians, facilities, health
plans, etc.
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Workflow Integration
• Prompting– User input required– Local or scheduled production
• Full Automation– Business logic fully defined– Scheduled production
• Demand
– User invokes letter
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Authorization – Refer To Provider Fax
11
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 12
CMS NDMC
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.© Ingenix, Inc. 13
ICE Comm Pre-Service Denial – Member Copy
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Commercial Denial -Referring Provider Fax Copy
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Business Overview
Organization • Multi-specialty, Clinically Integrated IPA formed in 1992
• Provides comprehensive administrative, contracting, practice management and clinical management services
• Represents over 525 primary care physicians and over 1200 specialists
• Multiple hospital partners
• Headquartered in San Francisco, network coverage in five counties, 250 employees
Members• Commercial HMO: 115,000
• Medicare Advantage (MA): 16,000
• PPO: 175,000
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Brown & Toland Business Overview
16
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Business Problem Overview
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Day Types and Benefits
• Inpatient Days – Unlimited for many plans but can be limited days to Benefit Period
– Copays and deductible based on benefit period days
• SNF Days– Most plans limit to 100 per Benefit Period
– Copays based on Benefit Period days
• Lifetime Reserve Days– Pool of 60 days as supplement to inpatient Benefit Period
limitation
• Mental Health Days– Classified as inpatient for basic limits
– Some plans have lifetime limit of 190 days
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Benefit Period Definition
• A period of time that begins on admission to a hospital or skilled nursing facility and ends when the member has been out of the hospital or SNF for 60 consecutive days
• “Non-Covered Days” (non-skilled custodial care, provider liability late discharge, etc.) are not included in the benefit period date calculation
• There is a slight difference in the way that Inpatient and Skilled Nursing days are counted when the member has exhausted benefits
Benefit Period Examples
MH 14
Begin Date4/1/14
End Date4/15/14
Benefit Period #2
170
InpatientLTRSNF
Period Start: Available Benefits
Mental Health
MH Used170
Period End: Available Benefits
Mental Health
MH Used156
InpatientInpatient UsedLTRSNF
100
6060
100 90 76
InpatientLTRSNF
Mental Health
MH Used
Period Start: Available Benefits
60
100 90
190
Period End: Available Benefits
Mental Health
MH Used
InpatientInpatient UsedSNFSNF UsedLTR
60
44
25
60
IP 10 SNF 25 I
PIP 8
IP SNF 50 MH 20Gap 50 Gap 55 Gap 50 Gap
12 Gap 30
Begin Date3/1/13
End Date1/13/14
Benefit Period #15 3
170
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Accumulator Project Inception
• Solution Requirements
– Consistent with CMS policies/definitions
– Integrated with FRM Claims
– Configurable at the benefit plan level
• Choice of Optum
– BTMG/Optum history and relationship
– Optum experience with FRM customizations
• Organizational Buy In
• Project Resources
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Accumulator Technical Design
• Requirements gathering and key design decisions
– Conceptual understanding of requirements
– Impact to claim processing time
– Defining date range for claim/inpatient days on claim
– Defining number of inpatient days
– Sculpting definition for Lifetime reserve
– Carving out the benefit periods
– Offering flexibility along with viewing and input utilities
• Thesis based approached• Duct tape and hot glue
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Solution Architecture
• Dictionaries and rule bank to offer flexibility for parameters• Stepped approach to adjudication• Real time processing to allow for accuracy• Utilities to allow for easy viewing of previous use and for manual entry
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MA Accumulator – Functional Overview
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Configuration - MA Accumulator Rule Bank
25
Rules determine Day Type of claim
Based on Bill Type and/or Location
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Configuration - Plan Limits Dictionary
26
Entry per Plan per Day Type
Benefit Period Limit
Day Type Group
Cost share models:• Deductible/days• Copay/admit• Copay/days – 2 tiers
Disposition Codes
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Configuration – Manual Day Entry
27
Test
Test
Manually Entered Admissions
• Service dates prior to BTMG facility risk contract
• Plan Risk hospitalizations
• Admit/DC based on inpatient authorizations
Data Elements populated determine how admit will be evaluated in adjudication
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Benefit Period Inquiry
28
Test
Test
Display by enrollment contract
Date range of each Benefit Period
Benefit Period Summary
Claims and Entries included
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Daily Copay
29
TEST, VYOLET L
Hospital Claim - 5 Inpatient Days
Check limits and cost shares
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Daily Copay
30
Test
Entries for plan effective on claim DOS
Choose by Day Type
No IP Day Limit
Copay –
$200/day 1-10
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TEST, VYOLET L
Daily Copay
31
$1000 Copay –
$200 per day of claim
Check Benefit Period Usage
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Daily Copay
32
TestThis claim represents
Inpatient days 1-5 of the Benefit Period
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Benefit Period Deductible
33
Hospital Claim - 44 Inpatient Days
TEST, EMILY C
Inpatient Deductible – Days 1 - 60
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Benefit Period Deductible
34
TEST, EMILY C$1216 Deductible
• Claim days = 44
• Dates 11/14-12/28/14
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Benefit Period Deductible
35
Test
Test
This claim starts a new Benefit Period
This claim represents Inpatient days 1-44 of the Benefit Period
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Benefit Period Exhaustion
36
TEST, EMILIO O
Mental Health Claim - 90 Inpatient Days
Check limits and cost shares
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Benefit Period Exhaustion
37
Emilio O Test
Inpatient Deductible – Days 1 - 60
90 Day Benefit Period Limit
190 Day Lifetime Limit
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Benefit Period Exhaustion
38
Emilio O Test
Emilio O Test
Last Benefit Period:
5/1 – 7/29/14
This Claim:
9/15 – 12/14/14
90 Day Limit already met
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Benefit Period Exhaustion
39
TEST, EMILIO O Message explains:
• Prior Day Type utilization
• Lifetime Reserve balance
Days rejected as above benefit maximum
Claim will NOT appear in Benefit Period Inquiry
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Lifetime Limits
40
TEST, EMILIO O
Mental Health Claim - 71 Inpatient Days
Inpatient Deductible – Days 1 - 60
190 Day Lifetime Limit
90 Day Benefit Period Limit
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Lifetime Limits
41
Emilio O Test
Emilio O Test
Mental Health - 140 Inpatient Lifetime Days Used Last Benefit Period:
5/1 – 7/29/14
This Claim:
10/5 – 12/15/14
New Benefit Period Start on 10/5/14
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Lifetime Limits
42
TEST, EMILIO O
Available Lifetime MH Days = 50Message explains:
• Prior Day Type lifetime utilization
• No reference to Lifetime Reserve
Days above maximum rejected
Days will NOT appear in Benefit Period Inquiry
Deductible taken
Days within limit approved
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Previous Exhaustion and Non Covered Days
43
TEST, VYOLET L
Skilled Nursing Claim - 21 Bed DaysBill Type 221 is Part B Only
Member’s Part A benefit is already exhausted
Occurrence Code 22 indicates end of skilled care – subsequent days are non covered
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Previous Exhaustion and Non Covered Days
44
TEST, VYOLET L
Message explains claim form element containing non-covered days
Days in Occurrence Span range rejected as non-covered
Day Type of claim set by Part B Only Bill Type
Remaining days rejected as exceeding benefit
These days WILL show in Benefit Period Inquiry
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Previous Exhaustion and Non Covered Days
45
Test
Approved SNF days = 100
Benefit Period extends through last date of skilled care, including days when SNF Part A benefit is exhausted
SNF Exhausted Days = 17
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Lifetime Reserve Days
46
TEST, MARY L
Inpatient Claim - 13 Days
Condition Code 68 indicates that member has chosen to use Lifetime Reserve days
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Lifetime Reserve Days
47
Mary L Test
Check of plan benefits shows 90 day Inpatient limit
If Lifetime Reserve, copay will be $608/day subject to MOOP
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Lifetime Reserve Days
48
Mary L Test
Mary L Test
Current Benefit Period Inquiry shows:
• 90 day limit already reached
• No Lifetime Reserve used to date
Last Benefit Period:
10/2/14 – 1/16/15
This Claim:
2/15/15 – 2/28/15
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Lifetime Reserve Days
49
TEST, MARY L Message explains Lifetime Reserve Days available and qualified days on this claim
Special disposition code used for LTR review
TEST, MARY LTEST, MARY L
Processor prices claim and approves days with special disposition code for LTR approval
Member’s MOOP met prior to this claim so no copay applies
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Lifetime Reserve Days
50
Mary L Test
Benefit Inquiry following LTR claim approval
Lifetime Reserve usage displayed
Claim in which LTR was used is noted in display
Benefit Period dates include days approved as Lifetime Reserve
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Impact on Operations
51
• Training and Go Live
• Procedural Documentation
• Workflow Changes
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