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.
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Key Issues in Healthcare Coverage
1. Key Issues in Health Care
Coverage
Dell Healthcare Services POV:
• Payment Integrity
• Utilization Management
• Provider Management
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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
5. 5
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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
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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
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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
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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
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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
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2
3
4
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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
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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
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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
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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.
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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?
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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