Operationalizing Requirements for Your Managed Risk Population: Achieving Accuracy and Compliance through use of Optum Technology Solutions Presented by:

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.


Agenda

• GE Healthcare/ OptumInsight Partnership

• Introduction to Optum’s FRM Solutions

• Brown & Toland Medical Group Business Overview

• Optum Medicare Advantage Inpatient Accumulators

• Questions



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


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


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


Financial Risk Manager Letters


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.


Workflow Integration

• Prompting– User input required– Local or scheduled production

• Full Automation– Business logic fully defined– Scheduled production

• Demand

– User invokes letter


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


Commercial Denial -Referring Provider Fax Copy


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


Brown & Toland Business Overview

16


Business Problem Overview


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


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


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


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


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


MA Accumulator – Functional Overview


Configuration - MA Accumulator Rule Bank

25

Rules determine Day Type of claim

Based on Bill Type and/or Location


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


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


Benefit Period Inquiry

28

Test

Test

Display by enrollment contract

Date range of each Benefit Period

Benefit Period Summary

Claims and Entries included


Daily Copay

29

TEST, VYOLET L

Hospital Claim - 5 Inpatient Days

Check limits and cost shares


Daily Copay

30

Test

Entries for plan effective on claim DOS

Choose by Day Type

No IP Day Limit

Copay –

$200/day 1-10


TEST, VYOLET L

Daily Copay

31

$1000 Copay –

$200 per day of claim

Check Benefit Period Usage


Daily Copay

32

TestThis claim represents

Inpatient days 1-5 of the Benefit Period


Benefit Period Deductible

33

Hospital Claim - 44 Inpatient Days

TEST, EMILY C

Inpatient Deductible – Days 1 - 60



34

TEST, EMILY C$1216 Deductible

• Claim days = 44

• Dates 11/14-12/28/14



35

Test

Test

This claim starts a new Benefit Period

This claim represents Inpatient days 1-44 of the Benefit Period


Benefit Period Exhaustion

36

TEST, EMILIO O

Mental Health Claim - 90 Inpatient Days

Check limits and cost shares



37

Emilio O Test


90 Day Benefit Period Limit

190 Day Lifetime Limit



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



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


Lifetime Limits

40

TEST, EMILIO O

Mental Health Claim - 71 Inpatient Days


190 Day Lifetime Limit

90 Day Benefit Period Limit


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


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


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



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



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


Lifetime Reserve Days

46

TEST, MARY L

Inpatient Claim - 13 Days

Condition Code 68 indicates that member has chosen to use 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



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



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



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


Impact on Operations

51

• Training and Go Live

• Procedural Documentation

• Workflow Changes


Documents

Operationalizing Requirements for Your Managed Risk Population: Achieving Accuracy and Compliance through use of Optum Technology Solutions Presented by: