SEC 10 - Solution Alignment with BMS Business Needs 10 - solution... · SECTION 10 SOLUTION ALIGNMENT WITH BMS’ BUSINESS NEEDS RFP §4.1.10 In Section 10, ... propose will provide

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©2011 Thomson Reuters ● All Rights Reserved ● www.thomsonreuters.com

SECTION 10 SOLUTION ALIGNMENT WITH BMS’ BUSINESS NEEDS

RFP §4.1.10

In Section 10, we describe the end-user functionality of our proposed DW/DSS solution and how it aligns with the Bureau’s business needs, goals and objectives. In addition, we demonstrate that the solution delivers the functionality identified in the RFP and supports the daily decisions of the various BMS work units. Section 10 is organized as follows:

10.1 Solution Overview 10.2 Advantage Suite: the Core DW/DSS 10.3 J-SURS for Program Integrity Data Analytics 10.4 i-Sight for Program Integrity Case Management

10.1 Solution Overview

10.1.1 Introduction Thomson Reuters proposes a DW/DSS solution that is well-aligned with the business needs of BMS. Our solution is based on commercial-off-the-shelf (COTS) software that is proven in Medicaid. The software is designed to be customized for each installation. No software development or modification is required, and no system integration is needed. That work has already has been done by us. The customization required is to add your unique data requirements and business dimensions to our standard Medicaid data model and design the standard reports that you want.

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The major solution components are:

Advantage Suite Data Warehouse — Built on an analytically-ready, robust, Oracle database, Advantage Suite provides the data warehouse that will store the Bureau’s data. The data warehouse will integrate, standardize, and enhance claims and managed care encounters, eligibility data, provider files − as many as 15 types of data to start. It will be built with four (4) years of data and will grow over time to house eight (8) years of data on line. We will update the data on a monthly basis. In Phase Two, the system can be enhanced with additional data, such as clinical data, PEIA data, and data from other programs. The data model and technology is proven and flexible can be expand to support more data, users, and applications. Thomson Reuters has a long track record for successfully and securely integrating public and private sector data for statewide analysis. Advantage Suite could become the State’s all-payer claims database (APCD) for far less cost than creating a separate database under a separate contract.

Advantage Suite DSS Applications — Advantage Suite provides an array of integrated reporting tools to support multiple user levels across the enterprise: interactive dashboards, prompted queries, standard reports, ad hoc reporting capability, record listings, and a personal health record. The system provides sophisticated analytics for budgeting, financial reporting, administrative reporting, medical policy, benefit policy, rate-setting, care management, predictive modeling, program oversight, and other applications.

J-SURS — J-SURS is the analytic workhorse of the state Medicaid program integrity community and the gold standard for surveillance and utilization review systems. The system supports provider and beneficiary profiling, exception reporting, and investigation. Thomson Reuters acquired J-SURS and its support staff in 2009, after J-SURS was installed in West Virginia. We propose to assume responsibility from Molina for the hosting and operation of the system, upgrade its hardware, add capacity, conduct a comprehensive data quality assessment and remediate if needed, and provide intensive training and consultation to BMS to rapidly increase the value of J-SURS to you.

i-Sight — i-Sight is an advanced, multi-functional, case management system for managing the daily work of the program integrity unit. Developed by Customer Expressions, i-Sight supports the efficient initiation of a case using a rules-based, decision-tree, question-and-answer interface. The system provides tools to manage and track cases, including automatic acknowledgements, notifications, escalations, reminders, and follow-up tasks. I-Sight also supplies pre-defined and user-defined reporting functionality.

Rounding out the solution are the following tools for extended capability:

• Cognos Report Studio and Event Studio, for power users to develop new dashboards and perform other production reporting tasks at will. BMS will not be dependent on Thomson Reuters for every reporting need, although we will have a full-time Senior Analytic Consultant on site to support you.

• ESRI ArcGIS Desktop, for designated users to do geographical analysis in full-color maps.

• SAS Desktop, for designated users to do advanced levels of forecasting, budget modeling, sampling, and predictive analytics.

Throughout Section 10, we will show how the sophisticated, yet easy-to-use, analytic functionality we propose will provide BMS with information to make better decisions, improve health outcomes, and make the best possible use of state and federal financial resources.

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10.1.2 Solution Track Record in Other States

The solution we propose has proven reliable in many state Medicaid programs.

Advantage Suite is in operation for twelve (12) state Medicaid/CHIP programs: Alabama (CHIP agency), Georgia, Idaho, Kansas, Maine, Missouri, Nebraska, Nevada, New Hampshire, Ohio, New York, and South Carolina. It is being implemented in two (2) more: North Carolina and North Dakota.

J-SURS is in operation for eleven (11) state Medicaid agencies: Alaska, Illinois, Louisiana, Maine, Maryland, Michigan, Mississippi, New Jersey, New York, Virginia, and West Virginia. It is being implemented in four (4) more: Indiana, Nevada, North Carolina, and Oklahoma.

i-Sight is being implemented by the Indiana Medicaid agency. Although i-Sight is new to the state Medicaid market, it is already in use by more than 300 organizations including two West Virginia state agencies:

• The West Virginia Dept of Corrections uses it for managing HR cases. • The West Virginia Insurance Commissioner’s Office uses it for insurance fraud investigations.

CMS Certification We have extensive experience with CMS certification. Our leadership status in the Medicaid technology community, and our commitment to keeping our systems MITA-compliant, will help BMS in achieving its vision of a MITA-oriented Medicaid Enterprise. We will ensure that the West Virginia DW/DSS meets the MMIS certification requirements, initially and throughout the life of the contract. Our solution complies with the traditional MMIS checklists for MARS and SURS and new MITA framework checklists. We have a 100% success rate being certified.

Using the traditional MMIS checklists, CMS has certified our solutions in several states. The DW/DSS solution, Advantage Suite, has been MARS-certified in three (3) states. The program integrity solution, J-SURS, has been SURS-certified in ten (10) states. Using the new MITA Framework checklists, Advantage Suite will undergo certification in five (5) states (three of these are in process) and J-SURS will undergo certification in at least three (3) states.

RFP 3.1.17 The Thomson Reuters solution complies with the CMS Medicaid Enterprise Certification Toolkit checklist requirements*, as follows:

Program Management Business Area

• Program Management Reporting (PM) Checklist • Federal Reporting (FR) Checklist (Offered as an Option; see Section 10.1.8.) • Decision Support System/Data Warehouse (DSS) Checklist

Program Integrity Management Business Area

• Program Integrity (PI) Checklist

Care Management Business Area

• Several of the population health reporting requirements in various checklists

* Requirements that rely on finalized claims data, i.e., data from paid, denied, or adjusted claims.

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10.1.3 Empowering BMS Staff to Make Better Decisions We understand that you are not buying services to do analysis for you—you are buying a system to empower your staff to be better analysts and decision makers. The Advantage Suite solution puts easy-to-use tools and actionable information in the hands of your staff, including those with non-technical skills. In addition, to help your staff gain familiarity with the systems, we provide the following services:

• During DDI we will provide at least six months of early user support by having a full-time Senior Analytic Consultant / Trainer available on site to work with prospective users from Day 30 of the project. This resource will involve users in report design, UAT preparation and training, post-implementation training, building an analytic agenda, and analytic skill-building. Skill reinforcement and confidence-building just before and after “go live” is an important factor in achieving user acceptance of the system, not simply to mark “Done” on the implementation plan, but also to ensure a positive experience for users who are early adapters.

• Early in the contract, we will provide a J-SURS specialist on site for three (3) intensive, week-long periods. We suggest these visits occur in months 6, 9 and 12 of the contract. This specialist will give staff in the Office of Quality & Program Integrity (OQPI) an opportunity for focused, in-depth skill development, coaching, educating, and problem-solving. The specialist can help BMS staff review and discuss the results of the comprehensive J-SURS data quality assessment that we plan to conduct in the early months of the contract.

• During Operations, we will devote a full-time, on site, Senior Analytic Consultant / Trainer to provide ongoing training, education, coaching, and mentoring. One of this person’s responsibilities will be to liaison with other resources at Thomson Reuters to continuously transfer to West Virginia ideas about how to apply the State’s new data and reporting tools. The full-time Senior Analytic Consultant will help BMS users create rapid value for the State and sustain beneficial results over time.

This specialized focus will:

• Empower end users to be stronger independent analysts.

• Increase analyst productivity.

• Increase range of skills using advanced analytics.

The ultimate objective of these services is to improve user skills and give them more confidence over time to use the systems every day – thus fostering the development of a more data-driven organization. Our long-range goal is to help you develop stronger knowledge workers who are able to use data to make more informed decisions.

10.1.4 Supporting a MITA-Oriented Medicaid Enterprise Thomson Reuters is committed to the principles of Services Oriented Architecture (SOA) and Medicaid Information Technology Architecture (MITA). Our systems and product development efforts are aligned with and employ SOA and MITA principles. Our status in the Medicaid technology community, and our commitment to keeping our systems MITA-compliant, will help West Virginia achieve its vision as a MITA-oriented Medicaid Enterprise at maturity level 4.

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The solution we propose reflects the MITA Principles and includes:

• A business-driven enterprise design. • Re-useable processes and architectures. • Web-enablement. • Data consistency across the enterprise, driven by standardized data and metadata.

Our proposed DW/DSS solution will support the BMS progression through the MITA maturity levels over time – another measure of our commitment to help BMS grow this system.

We have recently completed a five-year project to re-architect Advantage Suite, our core decision support system, using a Services Oriented Architecture (SOA). This new application architecture supports interoperability, component reusability, platform independence, and reduced cost of system development. The Advantage database provides analytically rich clinical aggregations such as admissions, episodes, and risk indicators. Now third party applications or programs can make use of the Advantage data. This opens up the possibility of enabling other applications to leverage the healthcare measurement intelligence available through the Advantage Suite measures engine.

Our proposed solution is based on:

• Use of COTS Software – MITA emphasizes the use of COTS solutions to lower cost, increase standardization, and facilitate interoperability. The DW/DSS we propose is a COTS solution that delivers the same underlying source code for each of our customers, but has been built to enable different configurations to meet distinct and unique requirements.

• Client-Centric View – Our proposed DW/DSS will provide a Medicaid client-centric view that is free from organizational boundaries and constraints. Thomson Reuters’ approach to healthcare data analysis has always been to consider the patient as the primary unit of analysis and to provide a client-centric, longitudinal view within our DW/DSS applications. Instead of being constrained within organizational silos, we have utilized a data model and other application methodologies that enable system users to view a client’s experience over time and without regard to organizational boundaries.

• Common Standards – Thomson Reuters closely follows standards development affecting healthcare, especially Medicaid and Medicare. In many cases we actively participate in and contribute to national standard-setting initiatives. We are committed to maintaining adherence in our products to widely accepted standards, and we invest our corporate research and development resources in keeping our products current with those standards. This commitment results in tangible value for our customers. For example, we are well underway in converting our systems to ICD-10 coding standards.

• Interoperability – It is important for systems to be able to reuse components. One of the top requirements noted in the MITA Technical Architecture is the use of a Service Oriented Architecture. A big part of the reduced cost of ownership and leverage of technology investments comes with SOA. Thomson Reuters healthcare application components are delivered using SOA, supporting the CMS vision of integrated business and IT transformation.

• Web-based – Thomson Reuters has moved toward web enablement of its applications in order to provide web-based access and integration. Our work in re-architecting our products is exemplified by the way we have made Advantage Suite fully web-enabled. We are continuing our efforts to provide web-based access and integration for all of our products in the future.

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• Software Reusabilty – Our project to re-architect our Advantage Suite DSS included efforts to put certain functions into separate modules that could be accessible and reused. For example, our Measures Engine has been structured so that it is accessible to other applications. Our development efforts are aligned with the MITA principle of software reusability.

• Public Health and Lab Data – Thomson Reuters has been active in enabling the use of public health and lab data within its healthcare DSS. Many of our Advantage Suite databases already include lab result data for use by clients. In addition, we utilize public health data in a variety of ways. In addition, our expertise with clinical data for our provider clients and our work in the Health Information Exchange (HIE) area will help enable BMS to achieve MITA maturity level 4 use of clinical data.

Our SOA-based approach provides the foundation to enable BMS to add more data, functionality, and access to the DW/DSS over time. SOA enables Thomson Reuters’ clients to link resources on demand. Thomson Reuters resources are made available to clients as independent services that can be accessed in a standardized way. Moreover, SOA enables easier integration of third party reporting tools with our proposed DW/DSS solution.

10.1.5 Balancing, Reconciliation, and Data Quality Thomson Reuters has earned a reputation for data accuracy and reliability. Our data quality standards are among the highest in the industry, because we are focused not on just the mechanics of building a database, but rather on the application of the data to achieve business results. Therefore, we strive to ensure that the data are not just loaded, but are qualitatively as well as quantitatively sufficient for advanced healthcare analysis.

We check source data for completeness, validity, and reasonableness, with specific edits for field incompatibility errors, incomplete field information, missing records, incorrect field values, and range validity. We use trend analysis to compare the quality of data over time and statistical process controls to look for unexplained aberrations. We check the database build process to ensure the data reconciles, with every update. We provide a monthly reconciliation report of the various data sources. We conduct reconciliation checks at several points during the processing and loading of data: after data extracts have been received, after converts have been run, and after the database build is complete. Balancing is a key requirement for the credibility of the system and is a prime focus for us. Historically, our builds balance to the penny with the source systems, at a high rate of consistency. The fact that our solution employs only one major dependent data mart, the J-SURS history file, helps mitigate the risk of out-of-sync conditions.

MDT DSS1.5 [CMS DSS1.6] Maintains synchronization of claims and encounter record dates with provider and Beneficiary record dates (i.e., a claim or encounter is always linked to the provider status and Beneficiary status segments associated with the date of service). Claims and encounter records will be synchronized with provider and beneficiary eligibility data in monthly records, so that the service data and monthly eligibility and provider status can always be compared. For example, DSS users will be able to run reports that expose instances where a provider was paid for a service rendered when he was under sanction or where a patient was ineligible for service.

Refer to Section 11.4.2.2 for a detailed description of our data quality assurance processes.

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10.1.6 Reporting Operations Reporting Operations includes the duties we will undertake to develop, run, and maintain the standard (pre-defined) reports that BMS needs for program management (PM) on a periodic basis: monthly, quarterly, semi-annual, or annual. The routine processing of standard reports is sometimes called ‘production’ reporting. Reporting Operations also encompasses the work we do to produce complex ad hoc reports and special consulting studies, if the Bureau requests our help. BMS users will also have the ability to design and run their own standard reports at will. Advantage Suite gives them the ability to schedule the reports to run at various intervals.

Customized Standard Reports

During Design, Development, and Implementation (DDI), Thomson Reuters will review in detail with BMS the Bureau’s needs for standard reports to meet the program management requirements represented in RFP Appendix 1, Section A, specifically requirements MDT PM1.1 through MDT PM 1.28. We will map the requirements to the library of report templates delivered with Advantage Suite; these templates may save time in customizing the Bureau’s standard reports. We have scoped our solution to customize, run, and maintain the following standard reports for you; more can be added at any time:

• Fifty (50) detail-level reports, which we will produce using the Ad Hoc Reporting component of Advantage Suite.

• One hundred (100) report components for dashboard and prompted summary queries. A report “component” is one item in a dashboard or query series or display. A sample report component is shown to the right.

If you have current reports or dashboards that you would like to produce from the new DW/DSS, our approach is to work with you to find the most efficient and economical method for delivering the information on those reports. We do this by replacing, not necessarily replicating, the legacy reports. For example, we may recommend deleting some reports if they are no longer needed, merging data from several reports onto one report, or adding new information based on your emerging needs. The multi-dimensional reporting capabilities of Advantage Suite are extensive and flexible, which makes report modification easier than it is with the tools BMS has today.

During Operations, we will produce the standard reports on the frequency that BMS requires. The Bureau has several options for adding more standard reports:

• Your users themselves can design and schedule reports to run on command or periodically.

• You may have your dedicated Thomson Reuters Senior Analytic Consultant design the reports in his/her available time.

• You may ask us to design the reports as an enhancement task.

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MDT PM1.28 [CMS PM5.5] Meets State defined time frames and priorities for processing user requests. Thomson Reuters will work out a schedule acceptable to BMS for producing standard reports and time frame for responding to user requests for help or special reports.

Reporting Operations: Meeting the RFP Appendix 2 Detailed Business Requirements

BSR PG1.22 Thomson Reuters will maintain a comprehensive list of standard PM reports and their intended use, including the business area supported.

BSR PG1.23 Thomson Reuters will maintain a list of users of each standard PM report.

BSR PG1.25 BSR PG2.21

Thomson Reuters will configure Advantage Suite to allow BMS users to save selected standard management reports, in static form, in online libraries, for the period of time specified by BMS, with the ability for BMS to alter the length of the retention period. We will work with BMS as part of ongoing operations to periodically review the size of the online libraries and agree to make adjustments when operational efficiencies may be needed. In any event, users will be able to save reports as templates and re-run reports at will against any period of historical data available in the online database. The Advantage Suite database will be configured to store at least 4 years of historical data to start, with the amount of online data growing over time to hold a maximum of 8 years of data. (Four years is specified in the CMS MMIS Checklist Requirement for PM5.4.)

BSR PG1.26 Thomson Reuters will configure Advantage Suite to produce the 150 standard reports (including Dashboard Report components) noted above under the heading “Customized Standard Reports” and to produce many more that BMS users may wish to develop over time. As noted above, we will work with BMS during DDI to define reports to meet your needs. Additional capacity, if needed, may be added as an enhancement at any time, economically and flexibly.

BSR PG1.33 Advantage Suite and our production reporting services provide the ability to meet all requirements identified by CMS and the BMS for report content, storage, maintenance, and file transfers.

BSR PG1.34 BMS users will have the ability themselves to produce outputs and data file extractions at will, except those that involve exceptionally large files. Advantage Suite provides users with an on-line feature to order extremely large extracts to be produced by the Thomson Reuters account team. We will work with BMS to establish guidelines for timing these extracts so as not to interfere with system performance in peak usage times. Our staff will produce extracts in accordance with the BMS's prioritization schedule, format, media, and distribution schedule.

BSR PG1.60 Thomson Reuters will ensure that the standard reports are developed in accordance with a production process we define together and that is approved by BMS.

BSR PG1.61 Thomson Reuters agrees that BMS owns the reports and that we will make no changes to reports without the prior approval of the BMS report owner(s).

BSR PG2.19 BSR PG2.20

As part of its Reporting Operations, Thomson Reuters will maintain a comprehensive list of standard reports, their users, and the intended use (business area supported) of each report.

10.1.7 MARS Reporting We encourage BMS to move the task of replacing the MARS Data Mart from the MMIS Fiscal Agent contract to the DW/DSS contract. We believe that Advantage Suite has the ability to produce the reports listed on the WV MMIS Master Reports List in the Procurement Library, assuming: (1) the exclusion of reports that rely on in-process transaction data, which should be produced by other MMIS subsystems (RFP §2.2); and (2) the requisite data elements are available from the Phase One data sources identified in the RFP (see Section 10.2.1.4, Data Sources). (RFP App. 2, BSR PG2.7)

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The benefits to BMS of moving MARS to the DW/DSS are as follows:

• It will save money. BMS will not incur the cost of hosting, developing, testing, operating, maintaining and backing up a separate MARS database. There will be no need for additional software license fees; we do not charge an additional license fee for using Advantage Suite as a MARS (or Federal Reporting) solution. We charge only for the additional processing capacity (if needed), and for the configuration, development, and ongoing production of the additional reports. We work from a set of federally-approved report templates to minimize the design effort.

• It will eliminate data redundancy and reconciliation issues. Having all management reports (except those that rely on in-process transaction data) produced from the same database and analytic reporting system will eliminate the inconsistencies in information that are likely to result from two separate sets of data transformation and query processes. There will be one ‘single source of truth’ – the DW/DSS – and it will be based on the trusted data quality procedures, consistent data transformation methods, and high-quality documentation of Thomson Reuters.

If BMS decides to move the MARS function to the DW/DSS, we would work with BMS to review the reports currently produced as well as the Bureau’s needs for new standard reports, just as we will do to meet the DW/DSS RFP Appendix 1 requirements. We will analyze each requirement against the capabilities of Advantage Suite Then we will estimate the hours to develop the additional reports and reach agreement with BMS on the scope and best timing of the enhancement task.

10.1.8 Federal Reporting MDT DSS1.9 [CMS DSS2.5] Supports Federal reporting requirements when these

requirements are met through the DSS. Federal reports can be produced from Advantage Suite, and several of our current Medicaid customers use Advantage Suite and Thomson Reuters’ services for this purpose. However, the work to develop, produce, and maintain all of the reports required by the CMS Medicaid Enterprise Certification Toolkit checklist for Federal Reporting (FR) would require: (1) additional labor for database and report customization and maintenance; and, possibly, (2) additional hardware processing capacity. We have not included scope for all Federal Reporting inside our base cost proposal, because the Federal Reporting requirements were in the MMIS Fiscal Agent RFP and were not listed in the DW/DSS Appendix 1 Mandatory requirements. However, the work to meet all FR checklist requirements would be more economically done under the DW/DSS contract than under the MMIS contract, we believe. We urge BMS to move this work to the DW/DSS contract. Our Cost Proposal contains pricing for this incremental additional work as an option for the Bureau’s consideration.

Federal Reporting: Meeting the RFP Appendix 2 Detailed Business Requirements

BSR CM1.10 This requirement, to collect and sort encounter data for use in completing the MSIS report, is related to CMS FR1.4. Our base scope includes the integration of managed care encounter data into the Advantage Suite database. Therefore, this data will already be available, should BMS elect to add responsibility for producing the MSIS extract to the DW/DSS contract. The labor to produce the MSIS extract is part of the optional pricing for Federal Reporting shown in the Cost Proposal.

BSR PG2.2 This requirement is the same as CMS FR2.1, to produce the CMS-416 EPSDT report. Advantage Suite is able to produce the CMS-416 and does produce it for other states. CMS has recently changed the CMS-416 specifications, and Thomson Reuters is already adapting our solution to comply. The labor to customize and produce the CMS-416 for West Virginia, as a standard report,

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Federal Reporting: Meeting the RFP Appendix 2 Detailed Business Requirements

is part of the optional pricing for Federal Reporting shown in the Cost Proposal.

BSR PG2.3 This requirement is the same as CMS FR3.1, to produce the CMS-372 waiver reports. Advantage Suite is able to produce the CMS-372 reports and does produce them for other states. The labor to customize and produce the CMS-372 for West Virginia, as a standard report, is part of the optional pricing for Federal Reporting shown in the Cost Proposal.

BSR PG2.17 Advantage Suite is structured at the service line level and applies the categories used in the CMS-64. The labor to customize and produce data for the CMS-64 is part of the optional pricing for Federal Reporting shown in the Cost Proposal.

BSR PG2.26 Advantage Suite will produce the data needed for the CMS 2082 report. The labor to customize and produce data for the CMS-2082 for West Virginia, as a standard report, is part of the optional pricing for Federal Reporting shown in the Cost Proposal.

10.2 Advantage Suite: the Core of the DW/DSS Solution Advantage Suite is a Medicaid-proven, Internet-based, healthcare enterprise decision support system that is fully integrated with a robust, analytically-ready, Oracle data warehouse. Advantage Suite delivers reporting and analytic tools for all user levels and for many business applications, without creating many disparate data marts that are difficult to reconcile and maintain. The Advantage Suite solution:

• Links disparate data to create a powerful, extensible, person-centric view of information; • Validates, reconciles, and standardizes the data to make it understandable and trustworthy; • Enhances the data it to increase its usefulness for population-based healthcare analysis; and, • Presents data to the user as immediately actionable information.

The integration of Advantage Suite’s analytic capabilities and powerful database supports rapid and efficient reporting across all of the Bureau’s systems and programs. (RFP App. 2, BSR PG1.35) Advantage Suite’s data model is ready now to add clinical data such as lab results as soon as that data is available to the State via WVHIN. The system’s SOA-based design and strong security enable the State, at any point in the future, to economically integrate data from PEIA, CHIP, other state programs, and even commercial payer data, to create an All-Payer Claims Database (APCD). We will start the implementation with our standard Medicaid data model and customize it for West Virginia. We will use our library of Medicaid report templates to build a customized set of standard reports to jump-start the Bureau’s analytic activity. The system’s ad hoc reporting is intuitive and user-friendly; your staff will be able to create reports at will. We will have a full-time Senior Analytic Consultant on site to continuously train, coach, and mentor your staff to make the best possible use of the entire solution.

We focus Section 10.2 on the functionality of Advantage Suite and how it meets the RFP requirements, helps the Bureau’s individual work units, and supports the attainment of your business goals related to Administration and Management, Operations Management, and Program Management.

MDT DSS1.10 [CMS DSS2.6] Extends system flexibility by adding enhanced reporting above and beyond what is available through other MMIS functions. With its “analytically-ready” database and robust analytic tools, Advantage Suite greatly extends the standard MMIS production reporting tools.

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10.2.1 Advantage Suite Functionality This section of the proposal addresses the functionality requirements listed in RFP Appendix 2, Section B.3, Business Intelligence, which are related to:

Data Access – Web Portal Outputs Scheduling BI General Query Help Functions Ease of Use Analysis Metadata Data Sources and Updates Presentation Administrative Functions

10.2.1.1 Data Access – Web Portal BMS users will access Advantage Suite from a multi-functional web portal that will provide a seamless pathway to all the data delivery tools that we propose. This web portal is called the Solution Center. It provides one-stop access to Thomson Reuters applications and content such as thought leadership articles and targeted news content. State-specific information such as annual agency reports, CMS guidance as well as analytic deliverables can also be posted and accessed. Single sign-on will be phased in for all applications over time. A sample of the Solution Center is provided in Appendix D.

The Solution Center also will link to the Thomson Reuters Customer Support Portal, where users can enter support questions and requests. The Solution Center also will link to the Service Planning Workbook, the account support planning and reporting tool that we use to track progress of work we do for you in meeting your analytic agenda, as well as reports on meeting service level agreements. This portal, in conjunction with e-mail notices, is also our means for keeping users notified about system availability, e.g., maintenance downtime, and about system performance issues if they may arise during production periods. The Solution Center is accessible via a security view. Access to each of the reporting components is based on user-specific security. Users who are not authorized for a specific tool, such as the Program Integrity tools J-SURS and i-Sight, will not be allowed to access those components.

BI Web Portal: Meeting the RFP Appendix 2 Detailed Business Requirements

TEC AC1.1 The Advantage Suite solution provides a web portal access component to the DW/DSS, called the Solution Center, that:

TEC AC1.2 Supports the seamless integration of the DW/DSS components delivered by Thomson Reuters, by providing an entry point for user navigation among the various reporting tools: static reports such as dashboards and prompted queries, standard reports, ad hoc reporting, J-SURS and i-Sight for Program Integrity, and possibly other optional tools in the future, as well as useful content such as external links to topical information.

TEC AC1.3 The Solution Center web portal is compatible with the Thomson Reuters data access and data delivery components.

TEC AC1.4 – TEC AC1.7

The Solution Center web portal will be accessible to all 60 BMS users; 30 or more users will be able to access the portal at the same time, and yearly growth of 10% is accommodated in our hardware configuration.

TEC AC1.8 As with all Thomson Reuters solution components, we will monitor the uptime and responsiveness of the Solution Center, as well as user access, to monitor and maintain acceptable levels of performance.

TEC AC1.10 With regard to the Web Content Accessibility Guidelines 1.0 developed by the World Wide Web Consortium (W3C), 12 guidelines on the Priority 1 Checkpoints list apply to the Report Center. We comply with 7 and have a product development plan to comply with the remaining guidelines in the future.

TEC AC1.11 Thomson Reuters will endeavor to conform to any State standards regarding the look and feel of the Report Center web portal, should the State adopt such standards in the future.

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10.2.1.2 Business Intelligence – General Section 10.2.1.2 provides a high-level overview of the major components, features, and functions of the Advantage Suite business intelligence toolset. Advantage Suite includes the following general business intelligence capabilities, which are described in detail throughout Section 10.2.

The Solution Center: This is a common, secure, Web-based portal that allows users to quickly access all of the applications and reports that Thomson Reuters will deliver, making information more accessible to business users in a comfortable, easy-to-use environment.

Static Reports: This is a location on the Solution Center portal for many types of pre-run reports. Users can rely on these reports for quick answers to commonly asked questions. Users will find specialized report content that BMS may have us prepare from time to time, as well as:

• Executive dashboards, an interactive, highly graphical, set of summary indicators that give managers an instant analysis of program performance. These extraordinarily easy-to-use and customizable report views give users interactive, cross-program performance measures with flexible navigation, to pinpoint meaningful information and answer questions quickly.

• Prompted queries, an extension of executive dashboards that allow casual users to specify report criteria simply by selecting items from a list before running a report.

Report Center: Advantage Suite is delivered with a library of standard reports for Medicaid, which can be run on a routine basis or used as templates for creating new reports. The Report Center templates are ideal for users who are not skilled analysts but do need to use specialized information, sometimes at the detail level, on a regular basis. Even for skilled analysts, starting from a template can save time.

Ad Hoc Report Writer: This is an advanced query and reporting tool with robust analytics that gives users direct, online, access to detail data. The ad hoc report writer has an interface that Thomson Reuters developed using Cognos by adding capabilities that are unique to healthcare reporting. The Ad Hoc Report Writer delivers flexible ways to use several unique analytics, such as:

• The Measures Catalog, with 2,000 pre-defined yet customizable measures of performance in healthcare, tailored to Medicaid.

• Subset Editor, an easy-to-understand data filtering capability that is tailored to healthcare reporting, delivered with a library of pre-defined subsets that are Medicaid-ready.

• The Patient Health Record, a unique, intuitive, visual summarization of the healthcare experience and prospective cost of each Medicaid beneficiary.

• Record Listing, a tool for rapidly and easily listing detail data from the system.

Finally, power users will have access to all the native capabilities of the Cognos Report Studio and Event Studio business intelligence toolset. Our proposed scope equips two (2) power users from BMS with a limited license to use the Cognos tools directly against the Advantage Suite Measures Engine. This access will enable BMS staff to design dashboards and other unique reports without having to rely on Thomson Reuters’ analytic staff, although our full-time analyst will be available to help when needed.

On the following pages, we provide more information about Advantage Suite’s components.

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10.2.1.2.9 User Levels

RFP 3.1.8 Provide 60 user licenses and allow for the purchase of additional licenses or user seats in minimum increments of one (1) to five (5). (As amended per RFP Addendum 1.) Thomson Reuters will provide Advantage Suite licenses to serve 60 users. We have provided pricing for additional licenses, as requested, in the Cost Proposal. See the table that follows for a breakdown by user level.

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BI General User Levels: Meeting the RFP Appendix 2 Detailed Business Requirements

TEC AC2.1 Advantage Suite is a Medicaid-proven, mature, intuitive, Web-based COTS solution that encompasses all of the following capabilities, seamlessly, in a single, comprehensive, easy-to-use integrated system: query, reporting, analysis, output and presentation, scheduling, help, metadata, and administrative tools.

TEC AC2.2 The Thomson Reuters Advantage Suite solution supports the users with tools that are appropriate to their skills and information needs:

TEC AC2.3 60 active users – A total of 60 authorized users are provided for in the scope of our proposal.

TEC AC2.4 30 concurrent users – All 60 users will be able to use the system at the same time to view, design, or run reports. We have estimated hardware capacity based on the assumption that 10 ad hoc reports will be running simultaneously, on average, which is consistent with our experience supporting other state Medicaid customers.

TEC AC2.5 The hardware configuration we have estimated will accommodate a yearly growth rate of 10% in usage, spread across all user levels.

TEC AC2.10 Advantage Suite provides interfaces that are tailored to all four user levels BMS has specified:

TEC AC2.11 Level 1 − 10 Executive users will have customized, static and interactive, dashboards with pre-defined drill-paths. See the heading “Dashboards”, previously in Section 10.2.1.2.

TEC AC2.13 Level 2 − 10 Casual users will have interactive dashboards as well as prompted reports (i.e., simple queries), and even detail-level standard reports from the Report Center that they may store in their own library, all accessible based on point and click technology.

TEC AC2.14 Level 3 – 30 Business analysts will have access to all the tools available to executive and casual users, plus the easy-to-use features of Advantage Suite’s Ad hoc Reporting tool that allows non-technical business analysts to explore the detail data using a catalog of drag-and-drop measures, subsets, time periods, and dimensions. The Report Center templates and the “Favorites” features will be important to business analysts, since they are likely to want highly specialized view of the data. They also may access the Patient Health Record.

TEC AC2.12 Level 4 – 10 Power users will have access to all the Advantage Suite tools available to Levels 1-3 plus the full features of Ad Hoc Reporting, to develop complex queries directly against the detail data. Two (2) of the power users will have the entire Cognos Report Studio and Event Studio to use against the Advantage Suite Measures Engine.

The tools described above by User Levels 1-4 correlate to the following break-out of Advantage Suite product licenses:

Advantage Site Dashboards with Prompted Queries 35

Advantage Suite Ad Hoc Report Writer 40, including 10 Power Users

Cognos Report Studio and Cognos Event Studio 2

The tables that follow provide our responses to the remaining requirements for Business Intelligence in RFP Appendix 2, Section B.3.

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RFP APPENDIX 2 BI REQUIREMENTS

THOMSON REUTERS RESPONSE

10.2.1.2 General

TEC AC2.7 Advantage Suite is designed to manage the production of the many standard reports, meeting common and repeated needs, for a typical state Medicaid agency. It has proven capable of high-volume production in states the size of West Virginia and larger. Advantage Suite also handles the daily production of ad hoc reports that are continuously needed in Medicaid.

TEC AC2.8 We will deliver Advantage Suite with a library of useful report templates to jump-start analysis. In addition, Thomson Reuters will customize additional reports for West Virginia during DDI. Reports are easily organized through the Report Center, a hierarchical folder structure accessible through the web portal. Users with proper authority can designate the folders as publicly or privately accessible.

TEC AC2.9 This solution provides robust functionality for both authentication and authorization to meet the strictest security requirements including HIPAA and other government regulations. This includes the following: ID/Passwords, Two-Factor authentication, encryption (HTTPS, VPNs, SFTP, PGP, etc), role-based security, security/audit logs, complex passwords, password aging, and account lock-out.

TEC AC2.15 Any report can be saved in “private” or “public” folders. In addition, reports can be secured to provide access to only certain users. This allows a report author to create a report and then make it available to any users he or she wishes, to be run or further modified.

TEC AC2.16 Dashboard reporting is a core component of the Cognos Report Studio which is delivered with Advantage Suite. In addition, Thomson Reuters will develop an initial set of dashboards for BMS. Dashboards provide instant visualization and understanding of large data sets, even to users with no training. The dashboards can also support drill-through to more detailed reports. The Advantage Suite tools, with built-in healthcare analytics, will be used to add informative value to the dashboards.

TEC AC2.17 Our project team can work with BMS to design web-based options for customizing views of summary data and making them accessible to external users. We do this for several other Medicaid agencies today. Also, BMS management may authorize us to give Web access to Advantage Suite to persons external to the agency, within the total user count provided in our scope, assuming the execution of a proper third-party access agreement to protect BMS and Thomson Reuters.

TEC AC2.18 BSR PG1.4 [CMS DSS3.6]

Advantage Suite provides an integrated set of general-level dashboards and parameterized reports, designed to provide indicators and general trends within and across the Medicaid population to fulfill executive information needs. Thomson Reuters has the most extensive experience in healthcare reporting in the industry. Our solution includes over 2,000 customizable measures covering almost every aspect of a Medicaid program. The massive Advantage Suite Measures Catalog provides the most robust Medicaid reporting solution on the market. Our measures are in use by over ten state Medicaid programs today.

TEC AC2.19 Our team will continuously upgrade and update the software and hardware over time to ensure acceptable response time and system availability. The software updates are available for no additional charge. Thomson Reuters has over 20 years of experience in delivering and supporting large, highly available software solutions.

TEC AC2.20 Users of even the most advanced capabilities of Advantage Suite do not need knowledge of SQL programming; the system generates the SQL code based on the user’s selection of easy-to-use, English query objects (measures, dimensions, time period, and subsets) that the user selects from a list and drops onto an intuitive report grid. If the user does want to see the underlying metadata, or measure definition, the “View Details” feature provides it.

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10.2.1.3 Ease of Use



TEC AC3.1 Advantage Suite has built-in data access components that make even complex healthcare population-based analysis a task that can be easily accomplished by users who are neither programmers, statisticians, nor full time analysts.

TEC AC3.2 Our solution offers a Graphical User Interface (GUI), the Ad Hoc Report Writer, which allows users with no knowledge of SQL to build reports ranging from simple to highly complex.

TEC AC3.3 Our solution allows users to add any or remove any measure from the catalog to any given report. Furthermore, power users can create new measures on any report. Power users can also create new measures within the database. All measure creation is done through a GUI and does not require SQL knowledge or the need to understand complex data structures or linkage techniques.

TEC AC3.4 All reports are available through the web portal and can be accessed simply by clicking on them. Any report can contain a combination of tabular data, charts, and maps. The mapping capability is provided with ESRI ArcGIS; two desktop copies are provided in our solution.

TEC AC3.5 The system is designed using Windows-based point-and-click, drag-and-drop capabilities.

TEC AC3.6 Executive users and casual users need only a brief familiarization of the web portal to begin accessing reports. Business Analysts will require from one to two days of training to build and run queries. Power users will require in-depth training, probably three days. Additional information is provided in Section 7.2.7, Training.

Other Appendix 2 Requirements for Ease of Use

BSR PG1.27 The Thomson Reuters solution gives authorized users direct, Web-based access to the J-SURS solution, as well as MARS reports, an optional capability. MARS reports are a seamless addition to the Advantage Suite Report Center, requiring no additional software to learn or manage.

BSR PG1.31 Users will be able to name their user-defined reports, subsets, and custom measures whatever name they desire. In addition, the system allows users to rename columns in a report before saving or sharing it.

BSR PG1.96 The ad hoc reporting capabilities of Advantage Suite are available to any authorized user at any time. We have planned hardware capacity to allow multiple users to be running queries at the same time. Users may opt to run reports immediately, over night, at a date certain, or on a regular basis. A formal change process is not necessary. However, if BMS desires, they may have Thomson Reuters design complex or specialized reports as a funded enhancement if they want to preserve the time of their users for other priorities.

MDT DSS1.12 [CMS DSS2.8] Provides online assistance to users to support effective use of

data query, data analysis, and report formatting capabilities. Advantage Suite features an intuitive user interface providing easy access to healthcare management reports. Advantage Suite’s powerful and easy to use ad hoc reporting tool allows you to further slice and dice data, change any report dimension on the fly, preview how the report will look. The Measures Catalog does a lot of the work for you, providing you with analytics and calculations you can trust. Formatting can be done with Cognos tools or through a hot-key export to Excel. Online Help provides expert guidance. The View Details feature makes easy-to-understand metadata instantly available. The Online Users Guide includes extensive clinical reference information, with more guidance available through links to Web-based resources. See Section 10.2.1.10 for more information on the on-line Help features.

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10.2.1.4 Data Sources and Updates Based on the RFP requirements and our extensive experience in Medicaid, Thomson Reuters has scoped this proposal to integrate the following data sources into the DW/DSS.

Phase One Advantage Suite Data Warehouse

We will convert and load up to fifteen (15) feeds of data representing four (4) years of history, including selected data elements as required from the following feeds. (The data source is the existing MMIS unless otherwise noted.) We are planning to load fully adjudicated claims, i.e., paid or denied, along with associated claim adjustment records.

(1) FFS institutional claims

(2) FFS professional claims (including medical, dental, and Medicaid mental health)

(3) FFS drug claims

(4) Managed care institutional claims *

(5) Managed care professional claims *

(6) Managed care drug claims *

(7) Eligibility and capitation data

(8) FFS provider files

(9) Managed care provider files *

(10) Waiver program data

(11) Prior authorization data

(12) Immunization file (to improve EPSDT results)

(13) – (15) Three additional data feeds to be determined, which can include budget data, waiver data, vital statistics, or similar data types.

With associated reference files.

* We assume the data from all MCOs will be delivered by the MCO Administrator in four single feeds/formats: institutional, professional, drug, and provider.)

Based on our experience with other state Medicaid programs, we are assuming the creation of 250 custom fields over and above the extensive number of data fields available in our standard Medicaid data model. This customization allowance has been proven sufficient to meet the needs of almost all of our other Medicaid customers. Not a hard-and-fast limit, this allowance is a guideline to help contain the risk, time, and cost of implementation and ensure an economical solution for West Virginia, especially during Phase One when expectations should remain focused on the most efficient way to get to production and show early value for the DW/DSS.

J-SURS History

During Phase One, while the Advantage Suite system is being implemented, we propose to take over operation of J-SURS from Molina, the Fiscal Agent, and continue to use the extracts Molina created for J-SURS to update the system’s history files every month. After Advantage Suite is implemented, we will be able to feed Advantage Suite and J-SURS efficiently from one set of extracts from the Fiscal Agent.

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RFP 3.1.5 Demonstrate a process for ensuring that data is representative of all data elements used for claims processing and payment. Thomson Reuters has earned a reputation for thorough, careful, comprehensive data management methods. Our processes, refined over 30 years and 300 decision support installations, ensure that (1) the database design accounts for every data element required to meet the State’s business needs, and (2) the data conversion and load process is complete, accurate, timely, and well managed, so that every data element is converted properly to the DW/DSS. Refer to Section 11.4.2 for a description of our data acquisition and management processes.

MDT DSS1.2 [CMS DSS1.2] At a minimum, transfers data from MMIS claims history, recipient enrollment, provider enrollment, and primary reference data (e.g., diagnosis, procedure, National Drug Code (NDC), and pricing) information. We have scoped the Advantage Suite and J-SURS support to store and integrate data from all of these sources.

MDT DSS1.3 [CMS DSS1.3} Accepts data in a variety of formats from a variety of additional sources, e.g., Vital Statistics, MCO encounter data, Benefit Manager encounter data (pharmacy, dental, mental health), Waiver program data, Census Bureau, other agencies or entities. Advantage Suite will integrate managed care encounter data, for a comprehensive picture of the entire Medicaid enterprise. That scope is assumed in the base Cost Proposal for Phase One. We also have assumed that the following data feeds are in scope: waiver program data, prior authorization data, immunization file data, and three (3) additional data feeds to be determined by BMS, which can include budget data, waiver data, vital statistics, census data, or claim files from other state agencies.

MDT DSS1.13 [CMS DSS3.1] Maintains easy access to data relevant to the needs of staff as anticipated in the APD and/or RFP, e.g., claims adjudication, prior approval, medical review, utilization review, and analysis of specific payment areas (pharmacy, dental, inpatient, etc.). Advantage Suite organizes data to make it very easy for business users to get specialized information. The Measures Catalog further speeds access, by presenting a wealth of pre-defined queries that are immediately relevant to the work of medical reviewers, pharmacy analysts, PA analysts, financial analysts, etc. Custom dimensions and subsets add more ways to tailor information.

Phase Two: Operations In Operations, we will update the data in Advantage Suite and J-SURS once a month with current claims/encounters, eligibility, and provider data. The data store will grow over time until eight (8) years of data, plus the current year, are online. At that point, we will begin rolling off the oldest data. BMS may choose at that time to have us expand storage capacity and allow the data history to continue to grow.

Weekly updates of Advantage Suite are an option that we can discuss with BMS at your request. We recommend that weekly updates, if of interest, are begun in Phase Two rather than Phase One, so that we can conserve resources for the Phase Two conversion to the new MMIS.

MDT DSS1.4 [CMS DSS1.4] Refreshes or replaces all historical claim data, recipient enrollment, provider enrollment, and other primary reference data on a scheduled basis. We will update the Advantage Suite data monthly, including claims, eligibility, provider enrollment, and related reference data. Weekly updates are available as an option. See Section 11.6.3 for more information.

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MDT PM1.8 [CMS PM1.9] Maintains provider, recipient, claims processing, and other data to support agency management reports and analyses. All of these data sources and others will be maintained in Advantage Suite and J-SURS throughout the life of the contract.

Phase Two: Enhancements BMS has indicated that the DW/DSS is to be designed to be expandable in terms of data storage and usage. Advantage Suite has a robust, extensible, data model that can integrate data from other sources than the MMIS, and several of our other Medicaid customers do use Advantage Suite that way. Potential enhancements identified by BMS include:

MARS and Federal Reporting – As indicated in Sections 10.1.7 and 10.1.8 above, MARS and Federal Reporting are logical extensions of the DW/DSS. Based on the results of the initial design effort, it is likely that all the data elements required to produce the MARS and Federal reports will be already be captured in Advantage Suite. The report customization work and ongoing production is all that is required.

Public Employees Insurance Agency (PEIA) – In three states, Georgia, Kansas, and Missouri, we use Advantage Suite to store the data for both the Medicaid agency and the state employee benefits agency. In addition, North Carolina also is implementing Medicaid and state employee data in Advantage Suite. For security, the data are stored in separate instances of the database, but Advantage Suite allows the data to be compared accurately. The combined databases give the states the power to improve their market leverage and better understand their states’ population health trends.

Data from other state agencies – In North Carolina where the Advantage Suite implementation has begun, the State plans to have Thomson Reuters integrate multi-payer data from all the State’s health agencies in addition to Medicaid: mental health, developmental disabilities, rural health and public health.

Clinical Data – For several years, Thomson Reuters has been integrating lab results in Advantage Suite for commercial health plan customers with access to this data. In addition, we already have configured the Advantage Suite data model to store and analyze additional types of clinical data once Health Information Exchange (HIE) has begun and data become available.

All Payer Claims Database (APCD) – In Kansas, the State is building an APCD by having us load commercial health plan data to Advantage Suite along with Medicaid and state employee data. Advantage Suite is an ideal vehicle for becoming the APCD, because it is already used for decision support by over 40 commercial health plans, 12 state employee programs, and 14 Medicaid agencies.



10.2.1.4 Data Sources and Updates

TEC AC4.1 Advantage Suite has the following capabilities.

TEC AC4.2 It can accept a variety of data sources, as described above.

TEC AC4.3 Users with proper training can import a list of user-defined values such as a list of IDs for questionable providers, claim numbers, or other such objects. The list can be saved and used in reports to include or exclude those values. For example, a user can import a list of Person IDs for

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patients participating in targeted disease management and track their progress over time, or exclude sanctioned providers from a profiling analysis.

TEC AC4.4 Users can save user-defined lists and use them with any other data set from the Advantage Suite database to further filter the data by including or excluding the listed values.

TEC AC4.5 TEC AC4.9

Thomson Reuters will implement its data management tool, DataProbe, as a part of the technical platform for the DW/DSS. DataProbe has the ability to rapidly and economically accept almost any type of data and make information available.

TEC AC4.6 The Subsetting feature of Advantage Suite allows users to create ‘virtual tables’ or views of data from the Advantage Suite data warehouse. Subsetting eliminates the overhead associated with storing multiple user-created physical data tables. Subsetting gives users the freedom to incorporate any data element in the warehouse at any time for any reporting purpose. The intuitive design of the system frees the users from having to care about where the data are stored. A unique capability within Advantage Suite – Study Group subsets – enables users to define a subset of patients or providers based on patterns of service utilization and link information for this user-defined cohort over time. This capability, not available with any other product, is critical for analysis of quality of care; it enables users to focus on patients with specific conditions and analyze the processes and outcomes of different treatment protocols.

TEC AC4.7 Advantage Suite allows users to import a list of user-defined values, use them to create a custom subset, and save the subset for personal, group, or enterprise use.

TEC AC4.8 The system allows the user to create lists of members, providers, provider groups, and codes.

Other Appendix 2 Requirements Related to Data Sources

BSR PG2.4 Advantage Suite is capable of performing the MARS reporting function, should BMS elect to have it do so. The database will be updated on a monthly basis.

BSR PG1.1 [CMS DSS1.5]

Advantage Suite and J-SURS are capable of storing an indicator that a claim attachment exists, if the indicator can be passed in the MMIS claim extract.

BSR PG1.28 Data fields to be included will be defined and agreed upon during DDI. Later, when a need for additional data elements is identified, they may be added as an enhancement.

BSR PG1.29 The data warehouse will store from 4-8 years of historical data from all planned sources.

BSR PG1.36 through BSR PG1.44

Advantage Suite will store data from all of the following sources: MMIS eligibility files, capitation, claims (paid/denied claims and claim adjustments, in bulk and in detail), managed care encounter data from the State's MCO Administrator, drug data from the MMIS or other contractor, BH data from the MMIS or other contractor, provider files, reference data, and other sources as may be defined by BMS. Initially, our scope assumption is up to fifteen (15) data feeds.

BSR PG1.46 Older data, once rolled off the online database, is stored until the end of the contract.

BSR PG1.97 During the contract, the off-line data is protected in accordance with HIPAA policy. At the end of the contract, the data are destroyed.

BSR PG1.56 The requirements process during DDI will determine the data the State needs for reporting. We will confirm the availability of the data and load it into Advantage Suite and J-SURS.

BSR PG2.1. Encounter data will be loaded and maintained in Advantage Suite, as noted above. Advantage Suite standardizes the managed care encounter and FFS claim data, to allow the user to compare experience in both programs accurately and fairly.

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BSR PG2.5 Advantage Suite has the ability to accommodate reporting across Medicaid services and social service payments regardless of service delivery method and financing mechanism, as long as the relevant data are available and the integration task is within the scope of the project. With regard to the State’s Master Data Management (MDM) system, Advantage Suite will be able to accommodate the additional fields of data that the MDM produces. We assume that the effort to add these fields will be a Phase Two Enhancement.

BSR CM1.1 Advantage Suite can store information on contracted MCOs, including geographic locations, capitation rates, and organization type, if provided by the MCO Administrator.

BSR CM1.2 Advantage Suite can store an indicator that a physician is a gatekeeper, the number of members assigned, and a quantitative indicator of capacity, if that data is available on the provider file.

BSR CM1.3 Changes to valid values usually can be accommodated within the standard monthly update process. Changes to the data model require an enhancement, which we can schedule with BMS.

BSR CM1.4 Advantage Suite will store run-off data, if available, after an MCO contract is canceled. The system also stores data on changes in enrollment resulting from changes in MCO offerings.

BSR CM1.10 Thomson Reuters produces MSIS submissions including encounter data in a number of states. Our standard Medicaid data model captures the encounter data elements needed for the MSIS filing. Services to produce the MSIS submission to CMS can be provided as an option. When CMS first required encounter data in the MSIS submission, CMS hired Thomson Reuters to do a national assessment on the quality of the encounter data being submitted.

BSR CM1.24 Within the given scope of data sources, the DW/DSS can store data needed to assess quality and appropriateness of care furnished to participants of the waiver program. The loading of RUGs indicators from the MDS can be included as a data source, at BMS’ option.

BSR CM1.27

Advantage Suite is able to integrate population health data from various external entities, including US census data, vital statistics, immigration data (as it may be stored in the MMIS or eligibility system), public health data, and other as defined by BMS during DDI. Please see Section 10.2.1.4 above for a list of data sources assumed in Phase One.

10.2.1.5 Outputs Advantage Suite produces report output with a variety of capabilities, as shown below.

MDT DSS1.11 [CMS DSS2.7] Supports a variety of formats and output options (e.g., Word, Excel, HTML, Access database, PDF or GUI format). Advantage Suite produces data in the following formats: HTML, PDF, Excel or CSV. Using standard browser capabilities, users can copy information from output reports and paste it for further analysis. When saving output outside of Advantage Suite in Excel or CSV format, users can cut, delete, paste, insert and copy additional information before saving.

MDT DSS1.6 [CMS DSS2.1] Supports simple queries and preformatted reports that are easy to access, follow a user-friendly protocol, and produce responses immediately. Users will have access to summary dashboards, prompted queries, standard reports, and report templates that produce information very quickly. See Section 10.2.1.2.1 for additional information.

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10.2.1.5 Outputs

TEC AC5.1 The output capabilities of Advantage Suite are described below.

TEC AC5.2 The solution supports a wide range of extract formats, including commas, tabs, and fixed positional format data extracts.

TEC AC5.3 Report outputs can be automatically run as .xls, .csv., pdf, and .html files.

TEC AC5.4 The selection of delimiters is part of the Advantage Suite Subset Editor.

TEC AC5.5 Advantage Suite enables the user to export reports to multiple sheets within an Excel workbook.

TEC AC5.6 The user may invoke the Internet Explorer print preview capability.

TEC AC5.7 Any report can present data in tables, graphs, gauges, or maps, or any combination thereof.

TEC AC5.8 TEC AC5.15 TEC AC5.19

The user may export data from Advantage Suite to the ESRI ArcGIS product, which provides geocoding (latitude and longitude) for enhanced mapping capabilities. We have provided for two desktop licenses in our Cost Proposal. ESRI ArcGIS allows the user to display Medicaid demographic data by type of delivery system on geographical maps at various levels (e.g., county, zip code, SMSA, state region).

TEC AC5.9 Two licenses are available for using Cognos Report Studio to prepare high fidelity, presentation ready, reports. In addition, any Advantage Suite user can export to Excel for special formatting.

TEC AC5.10 The solution natively supports report delivery via the intranet or e-mail. HTML output can be created for posting to the Internet.

TEC AC5.11 Advantage Suite is delivered with a Report Center that contains a wide array of pre-developed reports for Medicaid management. As part of DDI, Thomson Reuters will customize additional reports for BMS. In addition, users can create their own report libraries.

TEC AC5.12 Reports include full text names as well as a description, and can be organized in whatever directory structure BMS wishes. In addition, the solution includes robust search capabilities to facilitate easily finding reports.

TEC AC5.13 Prompted (“parameterized”) queries and custom subsets (“control files”) can be run from a menu and the output stored in directory libraries like other reports.

TEC AC5.14 All reports, custom measures, and custom norms a user creates or modifies can be saved and organized online in a private work area, or shared with others in public directories. Security views protect subsets that are stored in public libraries.

TEC AC5.16 Advantage Suite provides users with flexibility to create large data extracts to support complex analysis or third party use. In addition, users have the online ability to request even larger data extracts from the Thomson Reuters account team.

TEC AC5.17 The solution supports tables, approximately a dozen chart types, and mapping in any report. All report elements are printable and accessible in a variety of output formats, Including Microsoft Office. ESRI ArcGIS adds mapping capability.

TEC AC5.20 All report results can be saved once run, in any number of formats. Users can send reports to other people either as a file attachment or as a link in the web portal.

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TEC AC5.21 All report elements are printable.

Other Appendix 2 Requirements Related to Outputs

BSR PG1.30 If BMS has an Enterprise Document Management System (EDMS), users may use it to store Advantage Suite report output. However, users may also store report output on local LAN files.

BSR PG1.95 On-Line Help is available to assist users in creating data extracts and exporting them for format.

BSR PG2.12 Advantage Suite does not provide ability to display to the user the number of pages that are to be printed before the user prints. However, the user is able to view the report on-line before printing and scroll to see the size of the report.

10.2.1.6 Query Advantage Suite delivers extensive, advanced, query capabilities. The system is designed to make complex population-based healthcare analysis very simple. A key attribute of the system is that it masks the complexity of query creation by delivering catalogs of pre-developed, yet customizable, report objects commonly used for healthcare analysis: measures, dimensions, time periods, and subsets. The Measures Catalog is a particularly important query feature. It contains approximately 2,000 drag-and-drop metrics such as rates, averages, sums, and counts that would take thousands of hours to code by hand in SQL using a non-healthcare specific query tool. In Advantage Suite, “query design” means the simple act of selecting the easy-to-understand information objects that you want to appear on a report, and laying them out on an intuitive reporting grid the way the user wants to see them in the final report.



10.2.1.6 Query

TEC AC6.1 Advantage Suite delivers the following query capabilities.

TEC AC6.2 Queries are embedded in reports, which can be saved, modified, and shared. Queries are also represented by stored measures and subsets. Measures can be simple or complex; a single measure can represent hundreds of lines of SQL code.

TEC AC6.3 As part of the implementation, templates will be created specifically for key user groups. In addition, report authors can open any existing report and use it as a starting point for a new report. Also, Advantage Suite is delivered with a large set of report templates by topic areas such as eligibility, cost, utilization, and pharmacy.

TEC AC6.4 Advantage Suite presents a catalog of customer-specific dimensions (counties, eligibility categories, age groups, service types, claim types, etc.) that can be used as parameters to produce multi-dimensional reports. Any data element can be parameterized, and a report can include any number of parameters. Parameters can be presented to end users while the report is being viewed (e.g. as a drop down list at the top of the page), or as a wizard to allow users to select all parameters and then run the report.

TEC AC6.5 Advantage Suite includes a report validation tool that alerts the user to a design problem that may cause the query not to run properly. In addition, our user training includes guidance on efficient query design, with advice on how query design can shorten or lengthen run time.

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TEC AC6.6 Advantage Suite is built on an Oracle platform and supports all ANSI SQL statements such as outer joins, unions and intersections. Advantage Suite translates this to the user as user-friendly report design elements. The end user need not be aware of the underlying database structure, but the query structure is always available for reference online in the “View Details” feature.

TEC AC6.7

The system provides an extremely user-friendly way to run correlated sub-queries (multi-pass queries). The Subset catalog provides a list of summary measure subsets, which embody this type of complex query logic. In addition, the Study Groups feature allows users to link data on providers with data on patients and claims, across tables, in ways that are very understandable to the typical Medicaid analyst.

TEC AC6.8 The Advantage Suite Oracle database fully supports the use of ANSI SQL standards.

TEC AC6.9 Although Advantage Suite does not allow users to hand-code or import SQL, it does allow users to view the underlying query construction of each measure and subset. It allows users to construct a new subset easily, and users with proper training can modify or create measures.

TEC AC6.10 A report author can select any data element for a report, and select the layout of the report.

TEC AC6.11 BSR PG1.3 [CMS DSS3.5]

Advantage Suite allows users to drill down to detail data at will, as long as they have the authority to see detail data. For standard reports that Thomson Reuters designs for BMS, these drill paths can be embedded in the actual report.

TEC AC6.12 Power users have the ability to use any feature or function of the system to create ad hoc reports using any data element or combination of elements in the database.

TEC AC6.13 Any query on a report can be modified using the point and click interface.

TEC AC6.14 There is robust filtering in the “Subset Editor” feature. An export to Excel supports sorting.

TEC AC6.15 The tools we propose are designed to allow users to run complex queries without having to create SQL. For example, Advantage Suite’s Measures Catalog and Subset Editor convert complex SQL statements into English language objects. Users simply select from the thousands of objects available, which are organized in logical catalogs, and drop them onto report. Or, they can modify the object definitions at will.

TEC AC6.16 through TEC AC6.18

The Advantage Suite tools have robust subsetting capabilities including complex and/or logic, and a rich catalog of ready-to-use yet customizable dimensions and subsets that are healthcare-and-Medicaid-tested. For example, the Federal aid categories and provider types are already defined, as well as HEDIS-like cohorts such as members who qualify for certain preventive screens.

TEC AC6.19 Users can “hot-key” to Excel for re-sorting and re-grouping without having to run a new query.

TEC AC6.20 BSR PG2.10

Advantage Suite allows users to run unduplicated counts of members, providers, and services, e.g., visits, admissions, days, prescriptions, dollars. This important requirement is enabled by specific features in the physical data model.

Other Appendix 2 Requirements Related to Query

BSR PG1.2 [CMS DSS2.4]

The system allows users to retrieve and present data associated with geographic indicators such as by state, county, zip, state region, or groups thereof. There is a menu of many dimensions by which data can be viewed, not just geographic dimensions but also demographic, program, service type, clinical dimensions, and time dimensions.

BSR PG1.47 Advantage Suite’s interface provides easy-to-use search features with key-word capabilities, so that users can rapidly find the report, measure, benchmark, dimension, subset, subset criteria, or

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reference information they need. The Subset Editor is especially helpful, because every code has an English label and codes can be searched by their label as well as by the code itself. Diagnostic groupings are built in to further speed the subsetting process.

BSR PG1.54 A special strength of Advantage Suite is its built-in standards and benchmarks relevant to Medicaid and health care in general. There are hundreds of online, built-in benchmarks Utilization, Cost, Quality of Care, Outcomes, Prevention, Access to Care, Eligibility and Administrative Performance. Additional information is provided below.

BSR PG2.8 Every user with access to Advantage Suite’s Ad Hoc Report Writer will be able to create ad hoc reports at will. We have assumed there will be 40 users with access to the Ad Hoc Report Writer. Users who have access only to dashboards and prompted queries will also have pre-defined options for how they want to view the summary (static) information.

BSR PG2.11 Advantage Suite allows users to report based on the member enrollment hierarchy established by BMS. During DDI, Thomson Reuters will work with BMS staff to identify the various ways in which the Bureau likes to group its eligibility categories, member types, age groups, regions, and other dimensions for analysis. Then we will ensure that those dimensions are supported in the data model. Also built-in are the standard groupings that the Federal government requires.

BSR PG2.8 Every user with access to Advantage Suite’s Ad Hoc Report Writer will be able to create ad hoc reports at will. We have assumed there will be 40 users with access to the Ad Hoc Report Writer. Users who have access only to dashboards and prompted queries will also have pre-defined options for how they want to view the summary (static) information.

In the narrative that follows, we provide additional information about the powerful Benchmarking capabilities of Advantage Suite, an important query capability.

Benchmarking in Advantage Suite With the Benchmarking capabilities of Advantage Suite, BMS can easily compare its healthcare experience to the average (normative) experience of the commercially insured population in West Virginia, the Southeast region, the nation as a whole, or Thomson Reuters’ Medicaid customer base. The benchmarking feature automatically adjusts the experience of the referenced population to match the case mix and demographics of the West Virginia population. Episode-based comparisons are also adjusted by severity of illness. These powerful analytic methods, embedded in Advantage Suite, make it very easy to compare experience on an “apples-to-apples” basis, thus allowing you to isolate the variations to causes that you may be able to impact. Advantage Suite also provides online comparisons to benchmarks provided by third parties such as the American Academy of Pediatric guidelines for well child visits and the CDC Healthy People 2010 guidelines.

Advantage Suite includes national healthcare benchmarks based on empirical norms developed from the Thomson Reuters MarketScan database, the industry’s largest database of independently sourced, well-standardized, high-quality longitudinal health care information on the privately insured population in the United States. MarketScan provides national benchmarks as well as state-level benchmarks, and Medicaid benchmarks derived from the data contributed by our state Medicaid customers.

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MarketScan benchmarks are developed from the health care experience of individuals covered by Thomson Reuters clients nationwide. We collect this data periodically from more than 100 insurance companies, managed care organizations, and third party administrators, representing the health care experience of millions of covered lives annually. Thomson Reuters rigorously tests the data to ensure that it can be relied upon for valid normative comparison. Then, we select the highest quality data and apply methods to standardize, integrate, and enhance it to form the MarketScan database. MarketScan is a trusted source of information for academic centers and research organizations such as CDC, as well as many commercial and non-profit research institutions across the nation.

MarketScan benchmarks are available online to Advantage Suite clients who agree to contribute their own non-identifiable data to the MarketScan database and accept the terms of the Thomson Reuters Data Contribution and Use Agreement (DCUA), which ensures the confidentiality of the data contributors pursuant to HIPAA standards and Thomson Reuters’s own strict privacy policies. A copy of the DCUA is provided in Section 13 of this proposal. There is no additional charge for MarketScan benchmarks, as long as the data BMS contributes represents the entirety of its Medicaid program and the data meet MarketScan’s minimum standards for quality and completeness.

Best Practice Benchmarks

Also available are “best practice” benchmarks from the best performing 25th percentile of commercial customers. For example, for asthma, there are best practice benchmarks for:

• The percentage of asthma patients with complications. • The average number of outpatient visits for spirometries among asthma patients. • The percentage of asthma patients who received non-cardioselective beta blockers. • The average number of prescriptions for inhaled corticosteroids and cromolyn sodium drugs.

A few other examples of the best practice norms available include the following:

• Net Payment Per Day for Acute Inpatient Admissions. • Percent of Patients with Episodes of AMI who received Beta Blockers. • Office Visits Per 1000, for Patients with Diabetes. • Ophthalmic Visit Per Patient (Average) for Patients with Diabetes.

User-Defined Benchmarks

Advantage Suite also provides the ability to create your own custom norms as benchmarks, called “Dynamic Benchmarking”. Users can easily create an internal peer group norm (or “user-defined” norm) from any subset of the database. Users can select virtually any field or measure to compare individual providers or beneficiaries to their peers. For example, norms can be created that represent the peer group mean or upper or lower limit. Specific providers or beneficiaries can be suppressed in report generation and printing. Benchmarks can be quickly and easily created, stored, selected, and re-used. In addition, users can tell Advantage Suite to automatically calculate the difference and percent difference between each subject and the benchmark. Rather than calculate the norm, users can specify a value, or target, as the point of comparison, for example, Scripts per Patient Thorazine = 50.

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10.2.1.7 Analysis



10.2.1.7 Analysis

TEC AC7.1

Advantage Suite provides a wide array of analytic capabilities, many of which are specifically tailored to the analysis of healthcare experience. At the core of these capabilities is the data warehouse itself, which is designed using a ‘person-centric’ model. Any service information can be easily connected to a unique member or unique provider, without the user having to know what table, mart, or area stores the service data.

TEC AC7.2 Our solution provides robust multi-dimensional reporting, including slice and dice, drill-down (from the highest to the lowest level of detail), drill-up (from detail to summary with equal ease on any dimension of the data), drill across and pivot result.

TEC AC7.3 Advantage Suite provides extensive capability in this area. It has a wealth of flexible measures, dimensions, subsets and time periods in easy-to-use menus in the system’s Ad Hoc Report Writer. Users can drag and drop any object onto any report, pivot rows to columns or columns to rows, add dimensions and section breaks where desired, and see a preview of the report before its run. See below for information on the time period (“Periodicity”) feature.

TEC AC7.4 Advantage Suite allows users to drill down to detail data at will, as long as they have the authority to see detail data. For standard reports that Thomson Reuters designs for BMS, we can design these drill paths to be embedded in the actual report.

TEC AC7.5 Our solution supports math summarization: count, max, min, sum, average, standard deviation.

TEC AC7.6 TEC AC7.19

Advantage Suite assigns random numbers to certain data elements at the database level, to enable sampling. The random sampling feature produces an online record listing of every “nth” record based on any field you choose to sample. In addition, we provide SAS for advanced stratified random sampling. Advantage Suite users can easily extract data from Advantage Suite to import into SAS for sampling. The Advantage Suite Subset Editor enables the user to pre-stratify the data, so that the SAS sampling task is easier. J-SURS provides random sampling with appropriate statistics.

TEC AC7.7 Our solution provides formula building capabilities tailored to different users, with a point and click interface for simple mathematical expressions.


With Advantage Suite, users can summarize cost or use experience, and then model proposed changes to assess the potential impact. The user can perform prospective and retrospective policy modeling. In addition, SAS offers a wealth of ‘what-if’ modeling features; users can easily start their modeling effort in Advantage Suite by creating subsets of data to study, then export to SAS for the final stages of the modeling tasks.

TEC AC7.9 The metadata will allow users to see the rules that have defined any aggregation, summarization, or subset (filter) that has been pre-defined.

TEC AC7.10 Data can be pivoted and filtered along any dimension. Once the report has been run, the data are cached to speed the process of further slicing and dicing. The system will be tuned to support fast response.


Users will have various tools to access indicators of program performance. Advantage Suite delivers thousands of such indicators as flexible measures that users can select from menus. Just a few examples are:

a. Financial: e.g. per member, PMPM, PMPY, per 1000, per admission b. Eligibility: average enrollment, unduplicated members or recipients, measures by

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period of continuous enrollment c. Utilization: per member, per service, per provider, per episode, length of stay, many

population-based measures d. Access: ER rates, admission rates, complication rates, office visit rates

TEC AC7.16 Users can select multiple measures to report and apply weights to each measure and add the weights to calculate an overall score, such as for the degree of deviation from the norm for providers compared to their peers.

TEC AC7.17 Linear programming capabilities are provided in the SAS desktop software, two copies of which are included in our Cost Proposal

TEC AC7.18 Our solution provides two capabilities for predictive modeling: the statistical forecasting functions of SAS, and Diagnostic Cost Group models (DxCGs) in Advantage Suite. DCGs, coupled with the powerful analytics of Advantage Suite, allow BMS to produce both a current and a future forecast of utilization and cost, such as for estimating the future cost of a current population of people with chronic conditions or disabilities. Additional information on predictive modeling in Advantage Suite is provided below.

Other Appendix 2 Requirements Related to Analysis

BSR PG2.9 HEDIS Reporting The Advantage Suite Measures Catalog provides many measures of preventive care and quality of care. Some of these measures are based generally on HEDIS guidelines from NCQA and some are sourced from other standard-setting organizations such as AHRQ, NQF, and AAP. While based on standards, the measures in Advantage Suite can be customized by users to meet the unique needs of each customer. Should the Bureau need to produce NCQA-certified HEDIS measures, we offer an economical service that uses the Catalyst Quality Spectrum Insight (QSI) system, which is NCQA-certified. QSI allows users to produce HEDIS compliant measures and to customize reports. Refer to Section 15, Optional Capabilities, for additional information.

The Ad Hoc Report Writer is the gateway to the interactive analytic capabilities of Advantage Suite. Below we describe key analytic features of the Ad Hoc Report Writer. A sample screen is in Appendix D.

Advanced Periodicity Functions — Assessing healthcare measures over time is a critical requirement in healthcare data analysis. For example, one might ask: “How do costs for the most recent twelve months or fiscal year to date compare to the same period last year?” Advantage Suite includes numerous time functions that allow you to make time comparisons without having to explicitly define the date ranges. This allows you to define reports that can be run monthly without having to change the report definition to reflect the time period of each update. These advanced periodicity functions can be used for both incurred and paid date reporting. Certain relative time period comparisons can be made without entering explicit dates. The system will automatically select the appropriate time periods. In addition to the standard time periods, you may define periods, such as Quarters within a Fiscal Year, or specific ranges of months or days. Several pre-defined time periods are provided, including: Month, Quarter, Rolling Quarter, Calendar Year, Plan Year, Fiscal Year, rolling periods, and YTD.

Medical Episode Grouper — The Medical Episode Grouper (MEG) is an methodology embedded in Advantage Suite that organizes claim/encounter data for each patient into clinically relevant groupings

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that allow analysts to review the aggregate costs, treatments, locations (i.e., inpatient versus outpatient), and practitioners associated with the treatment of medical conditions. With Advantage Suite, the user has the tools necessary to use episode data meaningfully; the system delivers hundreds of pre-developed measures, benchmarks, and subsets that are episode-based. In most data warehouse installations, only an episode data table is created and the analyst must do the work to create meaningful information.

Predictive Modeling using DxCGs — Diagnostic Cost Groups (DxCGs) are the foundation of a family of risk adjustment payment and profiling methodologies developed by Verisk Health, Inc. The DxCG models are patient classification systems that help evaluate and forecast healthcare utilization and costs. The models use data from a specific timeframe to predict the expense of individuals in the same or subsequent time period. The predictions are based on the conditions and diseases for which an individual receives treatment over the specified period of time (usually one year) and the age and gender of the individual. We plan once a year to apply the DxCG All-Encounter model for Medicaid into the DW/DSS solution for BMS. With Advantage Suite, the user has the tools necessary to use the DxCG risk scores meaningfully; the system delivers pre-developed measures, dimensions, timeframes, and subsets that support analysis using DxCGs. In most data warehouse installations, the risk score is simply appended to the eligibility file; then the analysts must do the work to create meaningful information.

MDT DSS1.15 [CMS DSS3.3] Supports analytical staff through sophisticated analytical tools that perform specific analytical functions, e.g., statistical analysis, comparative analysis, financial trends, case-mix adjustments within time ranges specified in the APD and/or RFP. All of these sophisticated analytic capabilities and others are provided in our solution, as described above

10.2.1.8 Presentation



10.2.1.8 Presentation

TEC AC8.1

Advantage Suite, Cognos, and Excel function together to deliver the presentation capabilities of the DW/DSS solution.

TEC AC8.2 Advantage Suite allows for online maintenance of reports including addition, deletion, editing, copying, pasting actions.

TEC AC8.3 The solution provides a wide variety of data visualization techniques. It supports multiple chart types, as well as other graphic displays such as maps and gauges. In addition, it provides very robust exception reporting that can range from color coding numbers based on their value, to making entire elements of the report visible or invisible based the data.

TEC AC8.4 Our solution supports exception highlighting. For example, Advantage Suite allows a user to apply conditional formatting to a report and also allows the user to be alerted when the report has run. Users with access to the Cognos Report Studio can modify reports at run-time based on data thresholds or other parameter values. In addition, selected users will have available the Cognos Event Studio to support alerting, where users can be notified of an item of interest via the web portal or e-mail, even if they have not yet opened a report.


Information can be viewed in multiple formats, and reports can be stored and re-run to capture the most current information. In addition, users can have reports automatically run every time the database is updated. Also, users can store multiple versions of the same report.

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Graphs and Charts: Advantage Suite, in combination with Cognos Report Studio, offers you a range of graph types for data presentation. You have flexibility to define the format of graphs and can generate over 30 different types of charts, without having to export the data to another tool and you can create both two-dimensional and three-dimensional charts. Chart reports can be manipulated and customized by users within Report Studio. The examples below illustrate some of the charting capabilities available.

10.2.1.9 Scheduling



10.2.1.9 Scheduling

TEC AC9.1 Advantage Suite gives users options about when to run their reports.

TEC AC9.2 BSR PG2.6

Reports can be scheduled to run once or periodically. The report schedule can be set by any user with appropriate access. A Periodicity tool is available to allow users to design current-period trend reports and have the period automatically rolled forward whenever the report is run. Users with access to the Cognos Event Studio (2 copies are included with our solution) can schedule reports to be run based on a time or event trigger.

TEC AC9.3 Reports can be scheduled to run at a certain time and have the results e-mailed either as a file attachment or as a link to the Solution Center web portal.

Batch Jobs: Advantage Suite changes the traditional concept of “pulling” information when requested to “pushing” information when it needs attention. A job is a background process that is set up to run and send reports automatically based on a schedule or when some predefined event occurs. For example, you can schedule a set of queries to run automatically – on a set day each month. The job scheduling

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system allows you to schedule reports to run now, later, or on a periodic schedule. In addition, you can also define “events,” such as specific rules and thresholds that, will cause an alert when met (e.g., send this report to this list of users if percent increase > X percent). Using the job function, managers, and analysts can rely on the system to notify them of aberrant trends or significant outcomes instead of spending hours on daily monitoring.

10.2.1.10 Help Functions and Metadata



TEC AC10.1 There is a wide range of online Help features available in Advantage Suite.


The tools we propose come with user-friendly online help features including: how-to instructions with examples; searchable indexes; a glossary in the form of a look-up feature; robust metadata, English language definitions of every report element, an online user manual, online prompts, and extensive reference materials for clinical analysis.

TEC AC11.1 The metadata in Advantage Suite is extensive. The end-user form of online metadata is the “View Details” feature.

TEC AC11.2 View Details can be invoked from any query view, and hyperlinks take you to further detail.

TEC AC11.3 View Details has descriptive text and search features. Users can search for reports, subsets, measures, and codes using key words.

TEC AC11.4 TEC AC11.5

Users with authority can update the metadata (import) whenever they add a user-defined report object, such as a new measure. Any user can download the metadata to a .pdf file to export to other uses.

TEC AC11.6 The end-user metadata will be updated automatically every month, as part of the database update process. This will include refreshed look-ups, code updates, and code descriptions.

Online Help: Advantage Suite provides an online user manual, data dictionary, measures definitions, and analytic consulting guidance. Shown below is a measure definition from the metadata (called the “View Details” feature), which can be invoked from any query view. Additional information about the system’s metadata functionality is provided in Section 11.4.5. An example is provided in Appendix D.

10.2.1.11 Administrative Functions and Architecture



TEC AC12.1 − TEC AC12.4

Selected users will have available the Cognos Event Studio to create and apply rules for alerting users or managers when certain business thresholds have been exceeded, such as Net Pay > x. The alert will notify the user via the web portal or e-mail. In addition, for managers, dashboards can be designed to emphasize when certain business conditions, such as near-term utilization trends, require attention.

TEC AC12.5 Users may cancel queries, and the system administrator may terminate a runaway query.

TEC AC12.6 Users may save any version of a report, or save reports as templates to modify at will.

TEC AC12.7 There are several ways that the impact of proposed changes can be understood. (1) Monthly

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database updates: your Thomson Reuters Account Team will alert you to any changes in the source data and what impacts the change will have on your analysis. (2) Software updates; the Account Team will keep you informed of upcoming new product releases and their planned functionality, and provide you with an impact analysis when the new version is released; (3) You will have a test system that is a mirror image of your production environment, for testing new releases, major new reports, new data sources, or other important system changes.


Thomson Reuters will perform load balancing and fine tune the database when necessary to optimize performance such as query speed. If additional indexing is needed, we will perform that task, also.

TEC AC12.11 Users have the ability to create reports and report templates and place them in public libraries for sharing with other users. They can do the same with subsets, which are user-defined views of the data. The help of a system administrator is not needed to do this.

TEC AC12.12 The system will time out after 20 minutes of inactivity, which is a SAS70 operational standard.


Advantage Suite is a Web-based system using standard Internet design and technology. The system works effectively in a Web portal environment. Advantage Suite uses Cognos BI tools to deliver the system’s end-user interface and query generation. Power users will have access to all the native capabilities of the Cognos Report Studio and Event Studio BI toolset. Our proposed scope equips two (2) power users from BMS with a limited license to use the Cognos tools directly against the Advantage Suite Measures Engine. This access will enable BMS staff to design dashboards for the BMS user community without having to rely on vendor staff.

10.2.2 Meeting BMS’ Administrative and Management Goals

A major goal of BMS is to reduce redundancy in services and payments by integrating with other entities. The DW/DSS solution we propose supports that goal in the following ways:

• Its modern architecture, based on SOA and MITA principles, facilitates the addition of data from other entities, such as other public health assistance programs, CHIP, and PEIA.

• The person-centric data model and features of Advantage Suite make it easier to observe overlaps in service, gaps in service, and opportunities for service coordination.

• Even within the Medicaid data itself, having access to data that is better managed and organized will reveal data patterns not observed before. These patterns may indicate opportunities for new program efficiencies. For example, the powerful distribution reporting features and cost drivers analysis in Advantage Suite can spotlight areas of benefit limitation ‘leakage’ or gaming of the rules that can be addressed by changes in policy or reimbursement rate.

The DW/DSS solution we propose meets all of the following summarized requirements of RFP Appendix 2 that are related to the goal of improved administration and management:

[CMS PM1.18] BSR PG1.9 Analyze cost-effectiveness of managed care programs versus fee-for-service. [CMS PM1.20] BSR PG1.10 Report on any change from baseline for any program or policy change. [CMS PM3.7] BSR PG1.16 Provide information to assist with cost settlements. [CMS PM3.8] BSR PG1.17 Monitor individual provider payments. [CMS PM4.6] BSR PG1.18 Summarize expenditures by Federal category and eligibility type.

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[CMS PM4.7] BSR PG1.19 Provide eligibility and Beneficiary counts and trends by various data elements [CMS PM1.16] BSR PG1.24 Show hospice and inpatient days by hospice Beneficiary and provider. BSR PG1.57 Ability to [produce information that supports] retrospective reviews. BSR PG1.59 Determine if the services and billings were a medically necessary exception to

usual practice. BSR PG2.25 Provide listings of the Procedure, Diagnosis, and Formulary File.

10.2.3 Meeting BMS’ Operations Management Goals

BMS has three major goals related to Operations Management:

• Improve operational efficiency • Reduce healthcare costs • Measure compliance with operational performance measures

Our solution addresses all three goals in ways that also map to the RFP requirements, as follows.

10.2.3.1 Improve Operational Efficiency

MDT DSS1.7 [CMS DSS2.2] Provides ad hoc reporting capability that presents summarized information on key factors (e.g., number of enrollees, total dollars paid) upon request. The Advantage Suite Measure Catalog provides 2,000 measures, or factors, for easy ad hoc reporting. The measures include key indicators of program performance such as Patient Count, Net Pay, Net Pay PMPM, Net Pay Per Member, and many others. See Section 10.2.1.2.5 for more information on the Measures Catalog.

MDT DSS1.8 [CMS DSS2.3] Provides ad hoc query capability for retrieval of data relevant to specific operational units, e.g., claims resolution, prior authorization, and medical necessity review. Users can tailor their Advantage Suite tools to focus on the data immediately relevant to them. They can store their specialized reports in a personal or public library; they can store measures and subsets as Favorites. No time-consuming data manipulation is required; users have the data they need all the time.

MDT PM1.12 [CMS PM2.1] Reviews errors in claim and payment processing to determine areas for increased claims processing training and provider billing training. Advantage Suite can be used to help monitor claims payment accuracy and cash flow and assess the timeliness of reimbursement; for example, the system can be used to check that provider payments are consistent with policy and that new benefit caps and limitations are being properly applied.

MDT PM1.13 [CMS PM2.2] Provides claims processing and payment information by service category or provider type to analyze timely processing of provider claims according to requirements (standards) contained at 42 CFR 447.45. The system includes fully adjudicated claims (paid and denied) on which any type of reporting can be done: by Federal or State service category, provider type, specialty, or any other attribute in the database. The system supports analysis of processing turnaround times for fully adjudicated claims.

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MDT PM1.14 [CMS PM2.3 (modified)] Monitors third-party avoidance per State plan. If an indicator of third-party coverage is provided on the source files (eligibility or claim), Advantage Suite can be used to report on payments made that have potential for recovery.

MDT PM1.16 [CMS PM2.5] Provides access to information such as, but not limited to, paid amounts, outstanding amounts and adjustment amounts to be used for an analysis of timely reimburse-ment. We plan to load the DW/DSS with data on fully-adjudicated claims, i.e., paid or denied, and their associated adjustments. Timely payment analysis can be done on paid and denied claims.

MDT PM1.18 [CMS PM2.8] Develops third-party payment profiles to determine where program cost reductions might be achieved. The system provides a variety of capabilities for identifying areas where program cost reductions might be achieved, including recovery from third parties if third-party responsibility is indicated on the source data files.

MDT PM1.21 [CMS PM3.3] Analyzes timing of claims filing by provider to ensure good fiscal controls and statistical data. The system allows the user to analyze claims by date of service, date received, date adjudicated, date paid, and date adjusted (if applicable), as long as those dates are provided on the source files. Many other data elements from the claim file are also available for analysis. This data provides a significant source of information for statistical analysis and fiscal controls. Reports are available on the timeliness of claims filing by providers.

MDT PM1.23 [CMS PM4.2] Analyzes progress in accreting eligible Medicare buy-in Beneficiaries. Advantage Suite can produce the historical Medicaid spending data for members who are Medicare eligible, so that analysts can calculate the cost/benefit to the State of the Medicare Buy-In program. The system also can be used to identify Medicaid beneficiaries who are age-eligible for Medicare but for whom there is no Medicare membership indicator on their eligibility file.

Advantage Suite meets all of the following summarized requirements of RFP Appendix 2 that are related to the goal of improved operational efficiency:

[CMS PM2.10] BSR PG1.13 Automatically alerts administration when significant change occurs. (TEC AC8.4) [CMS PM4.9] BSR PG1.20 Provides the ability to categorize services based on benefit plan structure. [CMS PM5.1] BSR PG1.21 Supports report balancing and verification procedures. See Section 11.4.2.2. BSR PG2.14 Ability to demonstrate compliance with Federal prompt payment rules. BSR PG2.16 Ability to analyze provider and other claims processing errors. BSR PG2.18 Ability to analyze provider claim filing for timeliness, fiscal controls and ranking.

10.2.3.2 Reduce Healthcare Costs A major reason for investing in good decision support is to reduce healthcare cost. Listed below are merely a few examples of the many types of information you will have from Advantage Suite to help you understand the cost drivers in your program and how to set your priorities for action:

• Cost driver analysis – understand the major underlying causes of an overall spending increase. • Avoidable admissions – observe the inpatient admissions for ambulatory-sensitive conditions. • Readmission rate – see the hospitals that are experiencing above-average readmission rates. • Direct-to-consumer drugs – understand the impact on spending of mass-marketed drugs.

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• Gaps in prenatal care – find the connections between NICU use and lack of prenatal care. • Prospective risk scores – identify the patients whose care is likely to cost more than last year. • Chronic conditions utilization change analysis – measure progress in treating the chronically ill. • Top 10 Prescribers – intensely monitor the providers who are driving your drug spending.

10.2.3.3 Measure Compliance with Performance Indicators Measures and metrics are core capabilities of all of the reporting and analytical tools that we propose to BMS. Advantage Suite is one of the most reliable tools in the industry for healthcare performance measurement, in use by hundreds of healthcare organizations. Advantage Suite provides the ability produce quality measurement reports, as required by BMS. (BSR PG1.55) Our solution helps you:

• Measure results of policy changes – actual compared to plan. • Display and highlight trends in key indicators. • Measure across programs to compare relative efficiencies. • Compare the performance of individual providers and networks to their peers as a whole. • Monitor and benchmark many other aspects of program performance. • Set “best practice” indicators and compare providers against them, on a case-mix adjusted basis.

10.2.4 Meeting BMS’ Program Management Reporting Needs

BMS has two major goals that relate to program management reporting:

• Enhance BMS' ability to analyze the effectiveness of benefits and policies, using clinical data. • Use tools and training to enhance skills in data-driven decision-making.

10.2.4.1 Analyze the Effectiveness of Benefits and Policies

Advantage Suite provides a variety of methods for analyzing the effectiveness of benefits and policies regardless of whether clinical data (i.e., data from electronic health records) are available. Provided below are just a few examples of the analyses that can be done with administrative data (claims, eligibility) alone. For example, other State Medicaid programs have recently used our solutions to assess the impact of current or proposed policies including:

• Limiting the number of ambulatory visits • Covering home uterine activity monitoring • Covering gastric bypass surgery • Offering a chronic kidney disease management program • Implementing a pharmacy lock-in program • Many more decisions regarding expanding or contracting coverage

MDT DSS1.14 [CMS DSS3.2] Supports a range of analysis actions including: benefit modeling, clinical review, utilization management, provider-Beneficiary-MCO profiling, program planning, forecasting, program assessment, provider or contractor performance, quality assurance, fraud detection, comparison of fee-for-service and managed care, and other functions as described in the APD and/or RFP. All of these types of analysis are supported in Advantage Suite. J-SURS adds more specialized capability in fraud detection. See Section 10.3.

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MDT PM1.10 [CMS PM1.17] Analyzes break-even point between Medicare and Medicaid payments. Advantage Suite can produce the historical Medicaid spending data for members who are Medicare eligible. Analysts can calculate the cost/benefit to the State of the Medicare Buy-In program.

MDT PM1.27 [CMS PM4.10] Reports on dual eligibles. Advantage Suite can analyze the enrollment and cost of dual eligibles as easily as it does on any other eligibility group, as long as there are claims available and the claim carries the correct eligibility coding. You can report easily by any eligibility category or multiple categories, individually or in groups of the user’s choosing. You can report by aggregate statistics or drill down as far as the individual patient or claim level to perform analysis.

MDT PM1.11 [CMS PM1.19] Tracks impact of Medicare drug program. There are a wealth of prescription drug measures and reports available in Advantage Suite and many ways to model and track the impact of drug policy changes. Other states have used our DW/DSS to project and then monitor the impact of Medicare Part D.

MDT PM1.26 [CMS PM4.8] Provides Beneficiary enrollment and participation analysis and summary, showing utilization rates, payments and number of beneficiaries by eligibility category. Beneficiary enrollment trends, characteristics, and utilization rates and costs are a major use of Advantage Suite. A feature that helps with participation analysis is subsetting on period of continuous enrollment. This capability saves hours of tedious data manipulation to develop appropriate denominators; it allows the user to exclude from utilization rates the experience of beneficiaries who are new to the program or new to a particular managed care plan or PCCM.

Advantage Suite meets the following summarized requirements of RFP Appendix 2 that are related to the goal of program effectiveness:

[CMS PM1.10] BSR PG1.5 Counts days, visits, units, scripts, and unduplicated claims, bene’s, and providers. [CMS PM1.13] BSR PG1.6 Produces unduplicated counts within a type of service and in total by month. [CMS PM1.14] BSR PG1.7 Reports the utilization and cost of services against benefit limitations. [CMS PM1.18] BSR PG1.9 Analyzes cost-effectiveness of managed care programs versus fee-for-service. [CMS PM4.9] BSR PG1.20 Properly categorizes services based on benefit plan structure. BSR PG1.48 Allows user to perform prospective and retrospective policy modeling. BSR PG1.49 Checking of claims edits, rules, and payments; link adjustments to original claim. BSR PG1.50 Changes in Provider profile(s) such as type, location, networks. BSR PG1.51 Changes in Member(s) profile such as demographic groups, claim types. BSR PG1.52 Changes in benefit plans such as change in covered service or coverage limits. BSR PG1.53 Patterns in relationships between disparate data. BSR PG2.15 Ability to analyze areas of program expenditure to determine relative cost benefit. BSR PG2.22 Analyze changes made to benefit plans or rules by beginning and end dates. BSR PG2.23 Generate reports on service limitations and exclusions by benefit plan. BSR PG3.1 Compare managed care vs. FFS to determine best usage and payment scenarios.

Rate Calculations:

[CMS PM2.9] BSR PG1.12 Maintains data on per diem, DRGs, RUGs, other prospective payment methods. [CMS PM1.15] BSR PG1.8 Supports reimbursement [modeling] by HCPCS, ICD, Clinical Modifier, NDC codes. BSR PG3.2 Incorporates the Medicare fee schedule into rate calculations and comparisons.

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BSR PG3.3 Provides data to compute rates for reimbursement based on user calculations. BSR PG3.5 Ability to test rates against paid claims for impact or fair market rate analysis. BSR PG1.62 Ability to compare encounter data claims and capitation fees vs. fee-for-service

payment data to determine best utilization and payment scenarios.

Rate Calculations — In order to estimate the impact of new rates, Thomson Reuters can provide claims re-pricing as a service, as we do for other Medicaid clients. Our approach is to use our data management and exploration tool, DataProbe, to load the rates or fee schedule to be modeled and link the rates to the procedure codes from the Bureau’s paid claims records and associated pricing-relevant information on the provider. We also can load the Bureau’s fee schedule directly if it can be supplied by the MMIS. We produce output file summaries that the Bureau can import into a desktop modeling tool such as Excel. To perform this service, BMS may utilize available time of the dedicated Senior Analytic Consultant or may elect to use change hours. Depending on the source of data, the modeling analysis can be constrained if the fee schedule to be modeled is not time-lined, i.e., service occurred in the past but the only available fee schedule is for the present. Success depends on a team effort with BMS reimbursement experts. For an additional fee, we also can provide BMS power users with direct access to DataProbe.

10.2.4.2 Enhance Skills for Data-Driven Decision-Making The solution we offer delivers a DW/DSS that is intuitive and very easy to use, for which good online help and metadata are available. The information is robust and understandable, inviting exploration. The availability of good information usually generates the desire for more: BMS users are likely to explore. However, as with all new systems, usage may plateau after initial excitement, especially if users do not have time to experiment. Therefore, Thomson Reuters is proposing to put a full-time Senior Analytic Consultant /Trainer on site in Charleston during Operations to help reinforce classroom training and to mentor, coach, and support users to keep up the momentum for adoption and use of the new system. Our goal is to help your users gain mastery and maintain high usage of the system, so that BMS moves rapidly along the path to becoming a more data-driven organization. In Section 10.1.3, Empowering BMS Staff to Make Better Decisions, we present information about our approach to supporting you in this goal.

Finance and Budget are areas where the ability to make data-driven decision is vital. Advantage Suite has a wealth of capabilities to support financial analysis and budgeting. These capabilities include:

• BMS will have much higher-quality data for historical analysis than in the past. • Trend reporting is possible on sophisticated measures of program experience. • Financial fields are carefully tested and match to the penny with source data. • More than 300 pre-calculated, customizable financial measures are available. • Measures include sums, rates and ratios (per member, PMPM, per 1000, per admit, etc.). • West Virginia-specific cost/use norms are available as benchmarks, adjusted to your case mix. • Medicaid-specific cost/use norms are available, too. They also are adjusted. • Claim adjustment details are carefully managed so that Net Pay is accurate and consistent. • Claim completion factors make it easy to report on incurred cost in the near term. • IBNR reports are automatically generated, to assist with cash flow analysis. • Users can change from incurred-date to paid-date reporting at the click of a button. • Population-based predictive modeling capabilities enable more informed forecasting. • Excellent data standardization enables accurate comparison of managed care to FFS.

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The comment that follows from one of our Medicaid customers relates to Advantage Suite’s capabilities for IBNR reporting. “When we started this project, the DHHS liability calculation was a 2-week manual effort with many, many manual adjustments. Your work has produced a tool that significantly reduces this effort.” — Patty Fostier, New Hampshire Department of Health and Human Services.

Budgeting Capabilities BMS has requested analytic capabilities to support the daily work of budget tracking and forecasting. As a system for retrospective analysis, the role Advantage Suite can play is twofold: (1) as a reliable generator of high-quality historical baseline and trend data, and (2) as a tool for tracking actual expenditures to budget on a monthly basis. Tracking actual to budget would require BMS to select Budget data as one of the optional data types to be loaded in to the data warehouse. We have experience in several states loading budget files, and we can work with you during DDI to understand the types of budget files that Advantage Suite can use to support your work.

We also have included in our scope two desktop copies of SAS Analytics as part of the DW/DSS solution. SAS can play several roles in budget analysis, primarily as a powerful tool for forecasting future expenditures based on historical trends and other factors that the State may consider important in predicting cost in Medicaid, such as uptake in eligibility under health reform. Several of our state Medicaid clients use Advantage Suite and SAS or Excel models, in budget forecasting. They use Advantage Suite to develop historical trends, and then export data from Advantage Suite to SAS or Excel to forecast forward. Using Advantage Suite, they are able to rapidly manipulate the historical data and save time when doing iterative modeling; they can run reports, change them, re-run them, change again, and also run the same analysis against different dimensions of data and be confident that the information is consistent and comparable. Advantage Suite will provide you with new forms of historical baseline and trend data, through the power of the Measures Catalog. You will be able to analyze trends on per-member, per-patient, per admission, per-1000, per condition, per episode, PMPM, PMPY, and in many other ways − quickly and easily. You also will have available population-based prospective risk scores assigned to every member using the DxCG predictive models, another built-in feature of Advantage Suite. The responses provided below to the RFP Appendix 2.A.1 requirements are based on the capabilities of Advantage Suite, SAS, and Excel working together to support your budgeting tasks.

Formulate Budget: Meeting The RFP Appendix 2, Section A.1 Requirements

BSR PG4.1 Provides a budget data repository (budget module) organized to support budgetary functions (e.g., financial forecasting, tracking, reporting, development) and populated with the data necessary to perform those functions. Advantage Suite enables budget users to organize historical data they way they work, using Favorite measures, Favorite subsets, and their own report libraries. Summary budget data can be loaded to Advantage Suite, and user can use the Dynamic Benchmarking feature of the system to do monthly comparison of actual to budget, as long as the correct fund codes are available on the claims file to match to the budget data.

BSR PG4.2-BSR PG4.12

The system's budget module is to be minimally populated with [10 types of data]. All of the requested data will be loaded in Advantage Suite.

BSR PG4.13 Is able to automatically update data in the budget module on a monthly basis, and is capable of performing updates according to any other schedule established by BMS and upon demand. The Advantage Suite database will be updated each month with the past month of claims data, as well as current budget data, if BMS chooses to have budget data. Budget analysts will be able to access the new data as soon as the update is released. They will have direct online access to the database; they will not be dependent on someone else for extracts and there will be no

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waiting for a separate table or data mart to be refreshed.

BSR PG4.14 Is able to forecast expenditure estimates based on actual claim data. Advantage Suite will produce historical trend and baseline data for export to the Bureau’s selected forecasting tool. Users can easily export data from Advantage Suite into a file format that can be loaded into SAS. Advantage Suite provides a ‘hot-key’ export to Excel.

BSR PG4.15 Ability to export budget data to Microsoft Excel. Any data in Advantage Suite can be easily exported to Excel, with one mouse click.

BSR PG4.16 Ability to import budget data from Microsoft Excel. If the Bureau elects to have budget data loaded to the database, Thomson Reuters will load it each month at the same time the claims data are loaded. Users also have the ability to download data from Advantage Suite and import it into an existing or new Excel file. This is the approach that most of our clients use.

BSR PG4.17 Ability to provide a customizable Microsoft Excel export. Budget analysts typically use the ad hoc reporting features of Advantage Suite to set up their own libraries of reports as templates, and schedule them to run automatically every month after the database is updated. If budget data are loaded to the database, these automatic reports can be designed to compare actual to budget. The user also can automate the population of Excel macros with data from these standard Advantage Suite reports.

BSR PG4.18 Ability to add attachments at the detail level of the budget such as Microsoft Word, Microsoft Excel, and Adobe PDF documents. To accomplish this, the users would export data to Excel and insert a link in the Excel document.

BSR PG1.98 [Deleted by RFP Addendum 1]

BSR PG1.99 Able to concurrently support budgeting process for multiple fiscal years. Users can analyze multiple years of historical data and do trend analysis on based on a one-year or multi-year baseline analysis.

BSR PG1.100 Ability to allow users to modify specific budget numbers and not have to change the entire budget. If BMS elects to have budget data loaded to Advantage Suite, users can manipulate the reports that they prepare in Advantage Suite using the budget data.

BSR PG1.101 The system has the ability to track the original budget, including amendments made during the year, and distinguish between the two. In designing the budget table, we would work with BMS to design data fields to capture and distinguish amended budget amounts from the original budget amounts.

BSR PG1.102 Ability to provide a budget model or framework for forecasting purposes. Advantage Suite’s role is to produce historical trend and baseline data, which the user can then export to Excel or to a file format that can be imported into another forecasting tool, such as SAS. Advantage Suite provides the budget analysts with a rich array of tools for preparing whatever view or trend line they want, and to subset the data very discretely, to fit the forecasting model with which they may be working.

BSR PG1.103 Ability to provide budgetary control to control spending based on user-defined criteria. Advantage Suite’s role is to enable the budget staff to have powerful data on spending experience to guide them in making decisions on how to control spending. There are many features of Advantage Suite that will help the budget analyst: Dynamic Benchmarking, the Subset Editor, the Measures Catalog, and the ability to use Cognos Event Studio to set alerts when spending trends exceed or fall short of threshold amounts.

BSR PG2.24 Ability to generate expenditure, eligibility and utilization data by benefit plan(s) and/or any of its components to support budget forecasts, monitoring and health care program modeling. This

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function is the real strength of Advantage Suite; the Bureau’s budget analysts will find a wealth of new ways to study patterns in the historical spending rates than can help them make more accurate forecasts.

10.2.4.3 Program Management Requirements of RFP Appendix 1, Section A Compliance with the requirements in RFP Appendix 1 is important, since they comprise the majority of items on the CMS MMIS certification checklist. Our responses to many of the Appendix 1 Business Requirements (Section A) are presented elsewhere in Section 10 under topics that are relevant to those requirements. We respond to the remaining Appendix 1 Business Requirements below. All of these requirements can be met by the Advantage Suite solution, without customization, although the system is designed to be customized in terms of data model, system configuration, and the design of standard reports that reflect the customer’s unique needs.

MDT DSS1.1 [CMS DSS1.1] Identifies relationships between key entities in the Medicaid enterprise. The relational database organizes data in a Medicaid-specific person-centric model that relates data about patients to data about their doctors, their services, and the programs that cover them. Relationship patterns and trends can be readily discerned. See more about the data model in Section 11.4.1.

MDT DSS1.16 [CMS DSS3.4] Collects and summarizes data for specific user communities (e.g., data marts or cubes) such as program analysis staff, research group, and financial management unit. Detailed and summary data are provided in a single, multi-purpose, high-performance data warehouse, a design that avoids the need for many costly data marts or cubes that create opportunities for data inconsistencies and reconciliation problems. Only one major data mart is needed, to support the J-SURS specialized Program Integrity function.

MDT PM1.1 [CMS PM1.1] Provides information to assist management in fiscal planning and control. There are more than 200 financial performance measures available that can be applied to any report, and custom measures can be designed. The data are carefully reconciled and standardized to create a trusted source of consistent and reliable information. Sophisticated analytic methods are automated, such as IBNR, claim completion methods, incurred date/paid date reporting, and health risk adjustment. Trend reporting is facilitated by automating a variety of time period options. See Section 10.2.1.7.

MDT PM1.2 [CMS PM1.2] Provides information required in the review and development of medical assistance policy and regulations. There is a wealth of analytic capability in Advantage Suite to support the review and development of medical assistance policy. A robust population health reporting system, Advantage Suite delivers easy-to-use benchmarking, gaps-in-care analysis, best practice measurements, dozens of clinical groupings, case-mix adjustment, severity-of-illness adjustment, episodes of care, admissions, study grouping, and a wealth of pre-defined yet customizable measures to help with waiver planning, rate-setting, reimbursement policy, managed care, and many other tasks.

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MDT PM1.3 [CMS PM1.3] Prepares information to support the preparation of budget allocations for the fiscal year. Advantage Suite produces a wealth of reliable information for budget-setting. Expenditures can be trended by many dimensions, and there are hundreds of financial measures available to analyze cost per eligible and cost per recipient. See Section 10.2.4.2.

MDT PM1.4 [CMS PM1.4] Supports the projection of the cost of program services for future periods. Historical trend reporting is a particular strength of Advantage Suite; any of its 2,000 measures can be used to run a trend report. The most valuable attribute of the system is the careful way we cleanse and standardize the historical data, so that users can rely on the information being used to forecast. Users can easily export the history data to Excel or SAS to project past trends into future periods.

MDT PM1.5 [CMS PM1.5] Compares current cost with previous period cost to establish a frame of reference for analyzing current cash flow. There are a range of options for time period comparisons, including monthly, quarterly yearly, period-over-period, YTD, by fiscal year, calendar year, or plan year. For cash flow analysis, Advantage Suite provides claim triangles and the automatic gross-up of measures reported on a service-date basis in recent periods, to account for claims not yet reported.

MDT PM1.6 [CMS PM1.6] Compares actual expenditures with budget to determine and support control of current and projected financial position. Advantage Suite supports the comparison of actual expenditures to budget and calculation of the difference and percentage of difference.

MDT PM1.7 [CMS PM1.7] Analyzes various areas of expenditure to determine areas of greatest cost. Advantage Suite provides a powerful variance analysis of the major cost drivers in the Medicaid program – eligibility, utilization, and price – for a year-to-year change in expenditures, arrayed by category of service. “Top X” reports can be produced using any measure in the Measures Catalog.

MDT PM1.9 [CMS PM1.12] Tracks claims processing financial activities and provides reports on current status of payments. Advantage Suite can be used to track total payments made in the most recent, and prior, database update periods.

MDT PM1.15 [CMS PM2.4] Retains all information necessary to support State and Federal initiative reporting requirements. Advantage Suite can report on any aspects of a State or Federal program initiative for which relevant data is stored in the database.

MDT PM1.19 [CMS PM3.1] Reviews provider performance to determine the adequacy and extent of participation and service delivery. Advantage Suite provides a wide range of reporting capabilities for analyzing provider participation by location, time period, provider type and specialty, patients seen and patient characteristics, and total payment, and can produce numerous performance measures. ESRI ArcGIS can be used to quickly identify areas that may be underserved.

MDT PM1.20 [CMS PM3.2] Reviews provider participation and analyzes provider service capacity in terms of Beneficiary access to health care. The system analyzes problems with access to care: emergency room, office visit, and hospitalization rates for people with chronic conditions, per-person utilization rates, services by episode, services pre-and-post discharge, pre-natal care, and others. Provider capacity can be analyzed if capacity indicators are provided on the provider file.

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MDT PM1.22 [CMS PM4.1] Reviews the utilization of services by various Beneficiary categories to determine the extent of participation and related cost. Advantage Suite provides a variety of eligibility and utilization report templates to jump-start the review of beneficiary participation, by eligibility category, service category, geographically, and in many other ways. From these templates, many types of member access and usage reports can be produced.

MDT PM1.25 [CMS PM4.4] Presents geographic analysis of expenditures and Beneficiary/Provider participation. Users may study expenditures and participation rates by geographic area such as county, zip code, state regions, or statewide. ESRI ArcGIS will be available to produce data in map form. Geographic information can also be produced in tabular form.

Advantage Suite meets the following summarized requirements of RFP Appendix 2 that are related to Program Management:

[CMS PM3.6] BSR PG1.15 Produces provider participation analyses and summaries by different select criteria. [CMS PM2.7] BSR PG1.11 Identifies payments by type such as, but not limited to, abortions and sterilizations. BSR PG1.63 - Produces multi-dimensional, flexible, ad hoc reports across 31 business functions. BSR PG1.94

10.2.5 Meeting BMS’ Care Management Reporting Goals Advantage Suite is often used to do population based reporting to support care management objectives. Advantage Suite provides a wide array of analytic tools to study healthcare outcomes. Outcomes can be studied in many ways that do not require clinical data from electronic health records; however, such data, when available, will enhance outcomes research significantly. A key capability is the Measures Catalog, which contains many measures to identify adverse outcomes, for example the inpatient admission rate for asthma, a condition that, if treated properly, should not cause the sufferer to be admitted to the hospital. Admission rates and many other outcome measures are available for diabetes, coronary artery disease, depression, and other chronic but manageable conditions. Another type of adverse outcome is a “Never Event” – a preventable error in treatment having or potentially having a negative effect on the patient. Advantage Suite provides measures for Never Events and stores “Present on Admission” codes that are helpful in finding incidents that are true “Never Events”.

Managed care analysis is greatly facilitated by the careful way in which Thomson Reuters integrates Fee-For-Service (FFS) data and encounter data; we organize, standardize, and enhance the encounter data to enable the analyst to make accurate comparisons of experience between FFS and managed care, and between MCOs. Additionally, the Thomson Reuters solution will enhance reporting capabilities by calculating days and lengths of stay for claim types that do not typically provide days, such as managed care data. This further facilitates comparison between FFS and managed care plan types.

MDT PM1.24 [CMS PM4.3] Supports analyses of data on individual drug usage. The system produces a wealth of information on drug usage, which can be analyzed at the program level, provider, level, and patient level. The system includes a Patient Health Record (PHR) – a web-based graphical summary of usage by patient – that allows BMS to see a complete claims-based health history on a patient including their drug usage along with their clinical conditions and episodes. Medicaid agencies use the PHR to monitor the status of members in lock-in status, among other uses.

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Advantage Suite provides information and analytic methods that meet all of the following summarized requirements of RFP Appendix 2, Section A.2, that relate to Care Management Reporting:

BSR CM1.5 Provides information to support assessment of adequacy of provider network. BSR CM1.7 Reports on encounter data for the purpose of monitoring appropriateness of care. BSR CM1.8 Reports on encounter data for use in the determination of re-insurance & OOP costs. BSR CM1.9 Reports on encounter data for use in profiling MCOs and comparing utilization. BSR CM1.11 Collects and sorts encounter data for use in determining capitation rates. BSR CM1.12 Detects under-utilization of services by enrollees of the MCO. BSR CM1.13 Compares FFS claims and encounter data re: cost, timeliness, quality, outcomes. BSR CM1.14 Through encounter data, identifies persons with special health care needs. BSR CM1.15 Managed care reports by service category, eligibility category, and provider type. BSR CM1.16 Generates reports of capitation payment by various categories. BSR CM1.17 Reports on FFS for services carved out of a capitation agreement. BSR CM1.19 Distinguishes the 1115 expansion eligibles from other groups of Medicaid-eligibles. BSR CM1.20 Supports the budget neutrality reporting requirements in a state 1115 Waiver.

[See also BSR CM1.22 and CM1.23] BSR CM1.21 Reports to facilitate cost reporting and financial monitoring of waiver programs. BSR CM1.22 Monitors cost neutrality of waiver services to a target population.

[See also BSR CM1.20 and CM1.23] BSR CM1.23 Extracts data to produce annual CMS report on cost neutrality, amount of services.

[See Also BSR CM1.20 and CM1.22] BSR CM1.26 Ability to use MMIS data to support population health analyses. BSR CM1.33- Ability to analyze population health data to support health improvement and BSR CM1.38 population health initiatives BSR CM1.47 Ability to identify FFS claims covered under MCO benefit enrollees.

Review of New Enrollments BSR CM1.6 Provides information to support review of new enrollments and to prohibit affiliations

with individuals debarred by Federal Agencies. Thomson Reuters offers an optional Web-based service, CLEAR, that enables Government agencies to rapidly conduct background checks on applicants for status as a beneficiary or provider. Refer to Section 15, Optional Capabilities.

10.3 J-SURS for Program Integrity RFP §2.2 and App. 2, Sec. A.3 J-SURS is the established gold standard for SURS reporting. It remains the most popular SURS/FADS- dedicated application in Medicaid, with 11 installations and 4 more in implementation. Thomson Reuters acquired the system from UPI Government Group in 2009, after the system was installed at BMS through the Fiscal Agent contract. We are investing in J-SURS, with enhancements being released this year and other improvements under way. We intend to significantly improve the value of J-SURS to West Virginia. As the company that owns the system and knows it best, we can commit to its improved operation by assuming direct responsibility from the Fiscal Agent. If BMS approves, upon contract execution we will:

• Migrate the system to our data center and upgrade the hardware to improve performance;

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• Assume responsibility for the monthly history file updates;

• If not already done by then, install the OLAP Viewer (i.e., cube views of the data), which supports drag and drop slicing and dicing. Metrics are automatically supplied with the cube views, and advanced users can create metrics in the cubes. Coming soon will be TOPN listings within the OLAP Viewer. TOPN will give you on-demand listings of such things as:

o Top GPs and FPs physicians prescribing Oxycontin to females between the ages 35-55 o List of Providers of Diabetic Tests Strips Paid > $100K o List of GP Dentists who Bill for Oral Surgical Procedures

• If not already done by then, install the new UB feature, which provides the ability to drill down on UB revenue line data integrated with regular drilldown.

• Allow the database to grow over time to hold as much as eight (8) years of data online.

• Add encounter data for managed care oversight, if BMS desires.

• Deliver more licenses to you when you need them; our scope includes up to a total of 5 Report Generator licenses (power users) and up to a total of 25 Viewer/OLAP licenses.

• Conduct a comprehensive data quality assessment on the history file and remediate if needed. J-SURS experts will oversee the assessment and, with the Bureau’s permission, work directly with the Fiscal Agent to improve the monthly extract and build process, if that is what the assessment indicates should be done.

• Provide intensive on-site training, coaching, and consultation to the Bureau’s users, to rapidly increase the value of J-SURS to you. We are planning to provide a J-SURS specialist on site for three (3) intensive, week-long periods. We suggest these visits occur in months 6, 9 and 12 of the contract, approximately. This specialist will give staff in the Office of Quality & Program Integrity (OQPI) an opportunity for focused, in-depth skill development via coaching, educating, and problem-solving.

Thomson Reuters is focused on our customers seeing tangible results from our solutions, not just keeping the system in operation. We intend to work with you to make J-SURS as accurate, productive, reliable, and mission-critical to BMS as it is for our other Medicaid customers.

10.3.1 J-SURS Overview J-SURS is a data mining/report generating system using health claims and encounter data to produce comprehensive profiles of service utilization by healthcare providers and as well as profiles of services received by health system recipients. A CMS certified SURS system, J-SURS is both a powerful data mining tool and a robust report generator. It allows users to ask ad hoc questions and to respond instantly to issues that arise in the course of data analysis, i.e., there is no lag time for “programming” algorithms or complex queries. J-SURS places the analyst in control with access to critical information needed to target providers and recipients for review and audit. On an ad hoc basis, it allows users to easily perform the following functions, among others:

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• Access a library of proven FADS algorithms and reporting instructions maintained in a Parameter Data Base Library (PDB). Those algorithms built by the West Virginia users will be available in the new installation of J-SURS, i.e., they will not have to rebuild them.

• Design new report algorithms or queries. No programming or SQL knowledge is needed. This includes specification of what data is to be used in the query/report and allowing the user run the report and monitor its progress,

• View, manipulate and export the results on-line.

• Ability to easily “slice and dice” drilldown grid results by dragging, dropping and clicking.

• Archive the results/reports for future viewing, printing or modification for a new report.

J-SURS is not just a database query tool, answering one question at a time. It is also a fully integrated report generator. It affords the flexibility to do the following report tasks, among others:

• Use algorithms successfully tested in other states as well as develop customized algorithms. The selection of data is based on multi-dimensional combinations of claim/encounter/provider and recipient data elements. Use of the claims based class grouping function provides enhanced ability to focus reports and to develop customized algorithms. The selection of data for class groups is based on combinations of claim/encounter/provider and recipient data elements. Virtually any data element alone or in combination can be used to select the data for a report.

• Perform exception testing on user defined metrics against system generated norms and/or user supplied exception limits. This feature includes testing on exceeding a limit and also being below and threshold. There is also the ability to do “absence or zero” exception testing, e.g., identify any recipient under 18 months who has been enrolled at least a year and has no EPSDT services.

• Do frequency and duration targeting which allows users to specify frequency over time in selecting claims for class groups, e.g., select any provider who has more than 25 recipients with more than 10 services in a day.

• Perform Episode of Care selection for data selection and reporting. This is a particularly powerful J-SURS feature. It allows users to identify a target population meeting specific set of conditions and to analyze all the possible services related to the condition. As an example, users can identify providers with a pattern of billing pulp caps (procedure code D3110) whenever amalgam restorations (procedure codes D2140-D2161) were billed. A pulp cap should only be billed when a "pulp exposure" occurs when the filling is done due to significant decay encroaching upon the pulp (nerve of the tooth).

• Generate high/low frequency (drill down) displays on profiles and management summary reports of any data element values, including descriptions for codes and names. This particularly robust J-SURS feature includes the ability to limit listed values displayed to the top X and/ or to only those values with at least X occurrences. Users have the option to request displayed rankings of combinations of data elements in profiles.

• Perform comparative analyses using “exception processing” technology to identify “outliers” – unusual deviations -- from statistical behavior norms and models. This includes ranking of outliers for analysis based on the magnitude of their deviation from statistical norms of behavior models.

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• Develop “report cards” or profiles of the activities of any participant in the healthcare program including providers, health plans, Primary Care Providers (PCPs) and members (recipients).

All these capabilities are available to the analyst on-line, via user-friendly screens designed to allow non-technical staff rapid and easy access to information. All reports are designed in English. No programming jargon or knowledge is required. Screen features include:

• Immediate relational and value editing thus preventing incorrect values and deletion of critical dependencies.

• Profiling allowing users to generate profiles on the variety of different IDs that can be associated with the claim/encounter, e.g., servicing provider, pay-to (group) provider, tax ID, DEA ID, Long Term Care ID, recipient original ID, recipient case ID, managed care ID. A user can profile a Tax ID and identify the different servicing providers billing under the ID to identify unnecessary patient sharing among providers. J-SURS also profiles by NPI/API number.

• Health Plan/PCP exception profiling that integrates encounter data and enrollment/ capitation information and includes the ability to calculate Per Member per Month (PMPM) statistics.

• Long term care wrap reporting that allows profiling of long term care provider data from any dental providers treating the recipient while resident in the facility.

• Referral processing capabilities that include profiling of all referred services where the provider’s ID was the referring or prescribing ID. This includes the DEA number. All data elements from any type of referral claim are available for reporting.

• Point and click graphing and charting of metric results.

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User clicked on the metric Avg Pd per Recip and clicked on "Chart". The chart can be modified as needed.

J-SURS is designed to support the need for information in the dynamic environment in which waste, abuse and fraud are “moving targets.” With J-SURS flexibility, review staff can produce routine reports or fulfill one-time-only ad hoc requests for data. J-SURS liberates analysts from cumbersome mainframe-bound and hardcoded technology that is inflexible and slow.

The J-SURS development team at Thomson Reuters works continuously to add new functions and features to the system. One of the objectives of this development is to have a web friendly application that will provide new functionality to our customers. Examples of what is in development include:

• User “Alerts” automatically sent to a user when thresholds for specific activity are exceeded, e.g., greater than X number of high cost or control drugs prescribed, recipient visits or greater than X number of controlled drugs are received by a recipient across all providers prescribing.

• Hooks to Case Tracking. J-SURS will provide the “hooks” that allow for pushing and pulling data between J-SURS and a Case Tracking System (CTS) like i-Sight. It is generic functionality designed to allow links to any kind of tracking system. It includes:

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• Ability for users to do a lookup in J-SURS to see if there is a case for a particular provider or recipient. This data on cases is “pushed” periodically to J-SURS from the CTS in a format we can read and make available to users for lookup inside the J-SURS session.

• Ability to initiate a case in J-SURS and push it out to the CTS to a drive where it would be accessed by the CTS.

• Ability for users to create “packages” of reports that can be pushed to case tracking, e.g., profiles, claims detail, charts, OLAP cubes. They would be kept in directories where they would be available for access by the CTS.

10.3.2 How J-SURS Meets BMS’ Program Integrity Needs Across the country, J-SURS repeatedly has proven to meet every requirement of the Program Integrity checklist for in the MMIS Certification Toolkit. It also meets every requirement for Program Integrity in RFP Appendix 2, Section A.3, Program Integrity Management:

[CMS PI1.1] BSR PI1.1 Produces comprehensive statistical profiles of provider health care practices by peer groups for all categories of service(s) authorized under the Medicaid program (CMS).

[CMS PI1.2] BSR PI1.2 Automatically identifies deficiencies and generates reports on levels of care and quality of care by provider type (CMS).

[CMS PI1.3] BSR PI1.3 Automatically reports on the details of the practice of providers identified as exceptions or outliers (CMS).

[CMS PI1.4] BSR PI1.4 Provides the capability to profile provider groups and individual providers within group practices (CMS).

[CMS PI1.5] BSR PI1.5 Automatically identifies exceptions to norms of practice established by the agency for any type of provider covered by the State plan (CMS).

[CMS PI1.6] BSR PI1.6 Displays all data by National Provider Identifier (NPI) or by a subset of the provider’s practice (CMS).

[CMS PI1.8] BSR PI1.7 Performs analysis of rendering, ordering, and billing practices to generate reports of aberrant utilization and/or billing patterns (CMS).

[CMS PI1.9] BSR PI1.8 Applies clinically approved guidelines against episodes of care to identify instances of treatment inconsistent with guidelines (CMS).

J-SURS users can develop algorithms based on clinical guidelines; Advantage Suite users have a robust Measures Catalog that automatically incorporates clinical guidelines into episode analysis. With J-SURS and Advantage Suite together, BMS has the full complement of episode-based clinical treatment analysis.

[CMS PI1.10] BSR PI1.9 Generates early warning reports of high-cost services and service misutilization based on current payment data to quickly identify high volume practices (CMS).

[CMS PI2.1] BSR PI1.10 Automatically identifies exceptions to norms of utilization or quality of care standards established by the agency for any type of Beneficiary covered by the State plan (CMS).

[CMS PI2.2] BSR PI1.11 Tracks Federally-assisted program participants separately from other categories of assistance (CMS).

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[CMS PI2.3] BSR PI1.12 Identifies Beneficiaries who exceed program norms, ranked in order of severity (CMS).

[CMS PI2.4] BSR PI1.13 Identifies services received by Beneficiaries who are enrolled in selected programs (CMS).

[CMS PI2.5] BSR PI1.14 Identifies services received by Beneficiaries who have specified diagnoses (CMS).

[CMS PI2.6] BSR PI1.15 Links all services to a single Beneficiary regardless of the number of historical changes in Beneficiary ID (CMS).

[CMS PI2.7] BSR PI1.16 Profiles all services provided to a Beneficiary during a single episode of care (CMS).

[CMS PI2.9] BSR PI1.17 Has the capability to generate reports of individual Beneficiaries by peer group (CMS).

[CMS PI3.1] BSR PI1.18 Utilizes a minimum level of manual clerical effort in providing information that reveals potential defects in level of care and quality of service (CMS).

J-SURS and Advantage Suite together function to provide a rich array of capabilities for analyzing defects in the level and quality of care. Advantage Suite has “Gaps in Care” measures as metrics built into the system.

[CMS PI3.2] BSR PI1.19 Provides ability to perform analyses and produce reports responsive to requests from title XIX managers, QIO and State Medicaid fraud control units by means of computerized exception processing techniques (CMS).

[CMS PI3.3] BSR PI1.20 Selects claims and encounter data dating back to whatever time period is appropriate for the specific research (CMS).

[CMS PI3.4] BSR PI1.21 Supports the capability to produce claim and encounter detail and special reports by provider-type and Beneficiary classification (e.g., category of service—COS) and other key variables (e.g., Group Practice, Case) (CMS).

[CMS PI3.5] BSR PI1.22 Supports capability to perform focused review and to generate reports of all reviews undertaken (CMS).

[CMS PI3.6] BSR PI1.23 Has the capability to suppress processing on an individual within specified categories on a run-to-run basis (CMS).

[CMS PI3.7] BSR PI1.24 Provides access to all data elements outlined in the SMM Part 11, section 11335 and all additional data required for appropriate analysis of the program (CMS).

[CMS PI3.8] BSR PI1.25 Generates reports as needed (CMS).

[CMS PI3.10] BSR PI1.26 Facilitates export of claims-based class groupings such that data can be used by spreadsheet or database software (CMS).

[CMS PI3.11] BSR PI1.27 Supports fraud and abuse investigations (CMS).

[CMS PI3.12] BSR PI1.28 Supports pattern recognition and provides an automated fraud and abuse profiling system for the ongoing monitoring of provider and Beneficiary claims to detect patterns of potential fraud, abuse and excessive billing (CMS).

[CMS PI3.13] BSR PI1.29 Provides and stores all utilization reports in the medium designated by the State (CMS).

[CMS PI3.14] BSR PI1.30 Provides the flexibility to vary time periods for reporting purposes and to produce reports on daily, monthly, quarterly basis, or other frequency specified by the State (CMS).

[CMS PI3.15] BSR PI1.31 Maintains a process to apply weighting and ranking of exception report items to facilitate identifying the highest deviators (CMS).

[CMS PI3.16] BSR PI1.32 Provides for development and implementation of technical and user training programs (CMS).

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[CMS PI4.1] BSR PI1.33 Investigates and reveals misutilization of the state’s Medicaid program services by individual participants and promotes corrective action (CMS).

[CMS PI4.2] BSR PI1.34 Develops provider, physician, and patient profiles sufficient to provide specific information as to the use of covered types of services and items, including prescribed drugs (CMS).

BSR PI1.35 Ability to develop Provider and Member profiles sufficient to provide specific informa-tion as to the use of covered types of services and items, including prescribed drugs.

BSR PI1.36 Ability to provide standard BMS and CMS program integrity reports in accordance with BMS reporting standards.

BSR PI1.37 Ability to provide a mechanism to classify Members into peer groups for the purpose of developing peer group statistical profiles for comparative analysis using criteria such as:

BSR PI1.38- Age, Gender, Race, Geographic region, Aid Category, special programs codes BSR PI1.45 claims data elements, other as defined by BMS during DDI

BSR PI1.46 Ability to suppress (i.e., not generate or print) processing on individuals within a category of service or class group on a run-to-run basis.

BSR PI1.47 Ability to provide a mechanism to classify Providers into peer groups for the purpose of developing peer group statistical profiles for comparative analysis using criteria such as:

BSR PI1.48- Category of service, provider type, specialty, type of practice, enrollment status, BSR PI1.60 facility type, geographic region, billing versus servicing provider, number of beds,

claim data elements, provider ownership, referring provider, other as defined by BMS during DDI.

BSR PI1.61 Ability to develop Provider and Member profiles sufficient to provide specific information as to the use of covered types of services and items, including prescribed drugs.

BSR PI1.62 Ability to provide a mechanism to classify treatment for the purpose of developing statistical profiles by diagnosis codes or range.

BSR PI1.63 Ability to provide information which reveals and facilitates investigation of potential defects in the level of care and quality of service provided under the Medicaid program.

BSR PI1.64 Ability to track hospital readmissions for Members readmitted to the same or different hospitals.

BSR PI1.65 Ability to interface with the claims processing system.

BSR PI1.66 Ability to maintain appropriate controls and audit trails to ensure that the most current SUR data is used in all processes relying on the SUR data repository.

BSR PI1.67 Ability to conduct SUR across all Medicaid services and Social Service payments regardless of service delivery method and financing mechanism.

BSR PI1.68 Ability to provide SUR functions, produce management summary reports and to edit control file for inactive service codes, including procedure and revenue codes.

BSR PI1.69 Ability to generate statistical profiles for capitated plans, including the distinct profiling of Members associated with the capitated arrangement(s).

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BSR PI1.70 Ability to maintain random sampling techniques to extract data to support Provider audits, Member utilization analysis, and recoupment of funds.

BSR PI1.71 Ability to perform analysis of service and billing practices to detect utilization and billing problems to include but not be limited to:

BSR PI1.72- Incidental procedures, mutually exclusive procedures, unbundling of procedure BSR PI1.75 codes, bill splitting

BSR PI1.76 Ability to create random sample reports that include appropriate universe and sample totals to support analysis at varying levels of confidence.

BSR PI1.77 Ability to maintain a date driven parameter control file, with online real-time edit and update capability, which allows BMS staff to specify criteria, such as:

BSR PI1.78- Data extraction criteria, report content, date parameters, exception parameters, BSR PI1.82 weighting factors necessary to properly identify aberrant situations.

BSR PI1.83 Ability to generate frequency distributions and rankings for user-selected report and statistical items.

BSR PI1.84 Ability to review paid claims in order to: BSR PI1.85 Ensure that they are paid within BMS policy guidelines, and State and Federal rules BSR PI1.86 Ensure accuracy BSR PI1.87 Identify excessive quantities and duplicate billings for the same procedure BSR PI1.88 Identify excessive use of unlisted procedure codes and appropriateness of the use BSR PI1.89 Identify claims paid above their limitation

BSR PI1.90 Ability to use historical data to support the following types of investigations: BSR PI1.91 Provider utilization review BSR PI1.92 Provider compliance review BSR PI1.93 Member utilization review BSR PI1.94 Drug utilization review BSR PI1.95 Other as defined by BMS during DDI

[CMS PM3.7] BSR PG1.16 Provides information to assist auditors in reviewing provider costs and establishing a basis for cost settlements.

[CMS PM3.8] BSR PG1.17 Monitors individual provider payments.

BSR PG1.58 Identify claims that appear to have been inappropriately paid such as excessive units, duplicate services, coding errors, or other errors

10.4 i-Sight for PI Case Management RFP App. 2, Sec. B.3, and Vendor Question 84

A key BMS goal is to improve the process of Program Integrity and to reduce the effort required to achieve good results. A key strategy for achieving those goals is the acquisition of a professional, high-function, case management system to automate and streamline investigations and case management.

In answer to Vendor Question 84, BMS indicated that DW/DSS vendors should propose solutions for Program Integrity Case Management and that pricing for this capability should be included in the base price for the DW/DSS bid.

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Thomson Reuters proposes to deliver the proven i-Sight COTS software to meet the Bureau’s need for program integrity case management and case tracking capabilities. i-Sight will be one of the applications accessible to authorized BMS users through the DW/DSS web portal. We have provided in our scope for i-Sight to support seven (7) BMS users initially, based on the current staffing level of the Office of Quality & Program Integrity (OQPI). BMS may easily add users later, using the per-seat pricing for additional licenses for i-Sight as specified in the Cost Proposal.

10.4.1 i-Sight Functionality Overview i-Sight is a Web-based, advanced, multi-functional system for managing the daily work of the program integrity unit. The system provides tools to manage and track cases, including automatic acknowledgements, notifications, escalations, reminders, and follow-up tasks. i-Sight also supplies pre-defined and user-defined reporting.

i-Sight is being implemented by Thomson Reuters for the Indiana Medicaid agency. Although i-Sight is new to the state Medicaid market, it is already in use by more than 300 organizations including two West Virginia state agencies:

• The West Virginia Department of Corrections uses it for managing HR cases. • The West Virginia Insurance Commissioner’s Office uses it for insurance fraud investigations.

System Modules The i-Sight system is divided into three modules:

1. The first module is for the capture/initiation of cases. It was designed to provide users with a decision-tree question-and-answer interface. This interface enables even untrained users to easily and effectively enter new cases.

2. The second module contains tools to manage and track status of cases. This includes automatic acknowledgements, notifications (queuing), escalations, reminders, task management and bring forward/ follow-up tasks.

3. A third module supplies reporting functionality, which includes both predefined, and user defined reports (graphical and chart).

System Highlights • Web-Based - access and share information from any location. • Auto-Notification - used to notify appropriate staff of incoming cases. • Auto-Escalations and Exception Reports - used to inform managers of overdue items. • Extensive Reporting - includes performance, trend/ statistical reports, and Ad-hoc reports. • Easy Maintenance - for non-technical users to keep issue lists up-to-date, etc. • Intuitive Interface - easy to learn for any level of user.

Workflow i-Sight uses a flexible workflow to enable effective and efficient management of cases. During DDI, the system will be configured with an appropriate workflow that meets the Bureau’s RFP requirements. Some examples of workflow include:

• Automatic case assignment.

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• Task assignment notifications. • Task reminders. • Escalation (overdue) notifications. • Approval requests. • Closure notices

The basics of the workflow are driven by a Capture form, which initiates entry of new case information into the system. The capture form uses customized decision-tree criteria to continuously vary the input requirements and embedded algorithms to correctly notify, escalate, and route the case to appropriate personnel. Cases can also be initiated based upon the identification of suspicious behavior by providers or beneficiaries using J-SURS.

Cases entered into i-Sight could simply be recorded for statistical reporting, or, if further action is required, the case could be escalated. Within the Maintenance section of i-Sight, the Administrator defines notification rules to notify the person(s) of newly escalated cases. Typically, once notified, a manager is prompted to select a case owner or the selection process can be automated. That selection creates an automatic notification e-mail informing the case owner of the new responsibility. The notification e-mail includes a summary of case information as well as a direct link to the case file.

The case owner can access the case file where all activities and correspondence related to the case are tracked and managed. The workflow also monitors the case status and can be set to send reminders of upcoming deadlines, as well as escalation notices where deadlines were missed. When a case is closed/resolved, then automated notifications can be sent to various parties involved with the case (as well as managers overseeing various issues) informing them of the case outcome. Bring Forward tasks can also be embedded in the case file, allowing a case owner to be reminded of long-term commitments that occur months or even years in the future.

Capture Form We will work with BMS staff to configure the Capture Form that is used to submit new cases and other types of feedback. To create a new inquiry or case, the user steps through an intuitive, context-sensitive “wizard” that presents a series of questions and option-answer fields. All choices are based on decision-tree rules that will be established to meet your needs. If the information is not provided as required, instructive error messages are displayed and the user is prevented from continuing or submitting the case until the correct information is provided. This design ensures that even occasional users can submit cases without the need for training in the use of the application.

The Capture form records relevant information such as a description of the issue and desired action or outcome, a department categorization, and any other categories such as issue or service that may be of interest. All category selections are made using pick lists (which you can modify) to ensure speedy submission of new cases.

Case Record At the core of i-Sight is the Case Record, which contains all information related to a particular problem, including attachments in a single record. A case is automatically created each time the Capture Form is submitted. A case file can be logged (no follow-up required) or escalated (requires follow-up and/or investigation). Users of J-SURS will be able to initiate a case from their report viewers via their i-Sight

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interface. In addition, users have the ability to append reports and files to i-Sight. Access to all case files is limited by the “role” assigned to each user. Case records include a complete audit trail of all changes.

Action / Task Management Within each case record Action items can be created to track and monitor various tasks related to the case. These actions can simply be notes-to-self with reminder dates or can be assigned to other individuals for action. A key benefit of this exclusive i-Sight feature is that actions can be assigned both internally (to personnel who have system access) and externally (via e-mail) to other people who may be involved in case resolution, without the need for them to have access to the system or case files. Actions can be set up to have an action owner who will be responsible for its completion.

Flexible Reporting System users have access to real-time reports. Many reports are provided in a drill-down format so that the source data can be accessed from within the report itself. Reports are divided into three key types, Performance, Strategic, and Ad-Hoc reports. i-Sight reporting features include:

• Simple drag and drop web interface • Report creation wizards to assist novice users • Data Attributes displayed in agency not technical terms • Quickly publish organization reports to the web for collaboration

Search Functionality Cases can be accessed either through one of the case file listings or via the Search function. The i-Sight search engine provides the user with sophisticated full-text search functionality – allowing searches to be conducted on all data contained anywhere within the case files and attachments.

10.4.2 i-Sight: Meeting the Bureau’s PI Case Management Goals MMIS RFP, App. E, Sec. 6.1, DW/DSS RFP Vendor Question 84

Our proposed i-Sight solution for Program Integrity Case Management meets all of the following specifications in Appendix E, Section 6 (Program Integrity Management), Subsection 1 (Managed Case) of the Bureau’s MMIS RFP.

PI.1 Manage Case

PI.2 Ability to automatically generate a unique case identifier upon referral for Case Management. Identifier methodology to be specified by BMS.

PI.3 Ability to automatically create the Case Management record (from the initial case review data) upon referral to Case Management.

PI.4 Ability to track and maintain Case Management data at the individual case level, including:

PI.5 Case number PI.6 Case Manager PI.7 Case status (e.g., open, suspended, closed) PI.8 Type of review/investigation PI.9 Initiating agency

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PI.10 Reason for inquiry/review PI.11 Review time period/case schedule PI.12 Actions taken

PI.13 Providers placed on a hold and review status, the reason for hold and review status, and dates of hold and review

PI.14 Outcomes including monetary recoveries, such as recoupments

PI.15 Listing of case contacts/affected parties

PI.16 Disposition (e.g., corrective action, Medicaid program membership termination)

PI.17 Chronology of significant case activity (e.g., dates of phone calls to Providers, dates of records/information received from Provider/Member/attorney), including description

PI.18 Significant case documentation/evidence (e.g., medical records, Member interview findings, Provider credential verification)

PI.19 Referrals PI.20 Recoupments PI.21 Location of treatment PI.22 Other as defined by BMS during DDI *

PI.23 Ability to track and maintain case detail, including:

PI.24 Unique case identifier PI.25 Case description PI.26 OQPI (Office of Quality and Program Integrity) staff investigating the case PI.27 Date received PI.28 Source of case PI.29 Status (e.g., under review/results pending, closed, referred to Case Management) PI.30 Other as defined by BMS during DDI *

PI.31 Ability for the user to enter free-form text in a field and display narratives in chronological or reverse chronological order. Each entry is expected to include identification of user and date/time entered.

PI.32 Ability to automatically generate a unique system identifier for all cases under initial review. This identifier should indicate "under review" status, and is expected to be different from the Case Number assigned upon referral to Case Management.

PI.33 Ability to integrate and analyze data from external sources (e.g., vendors) in multiple media types.

PI.34 Ability to contain finalized claims, finance, and clinical data reconciled to PCN (Payment Control Number).

PI.35 Ability to generate and track SUR/Fraud questionnaire letters to Members and Providers according to specific criteria, with the ability to change the criteria real-time.

* With regard to “other” requirements (PI.22 and PI.30 above), the following aspects of i-Sight can be

customized as part of the set-up and configuration process, and are considered within the scope of this proposed implementation.

1 Intake / Capture Form – The Intake Form includes data required to be captured upon initiation of a case. As part of the configuration, we will configure the fields listed on the intake form, by: (1) defining the form for various case types, (2) defining dependency between category fields (up to 5

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levels), (3) defining the field names and types (numbers, text, mandatory, etc.), (4) Email-to-case generation.

2 Workflow – We will configure workflow rules required to optimize the business process. As part of the configuration, we will configure any of the following workflow rules. Each of the following workflow notices can be based on up to 2 parameters (for example notifications could be determined based on case type and issue, or business unit and location, etc.). This includes: (1) auto-notifications of new cases (can be based on up to 2 parameters), (2) auto-assignment (can be based on up to 2 parameters), (3) case or action owner reminders, (4) approval requests, (5) escalation notices (overdue), (6) closure notices.

3 Case Record / Management – The case record will contain the following standard functionality, including the ability to: (1) assign a case by selecting an owner from the pick list, (2) add multiple contacts to a case, (3) record notes using the actions, (4) set follow-up tasks with reminders using the actions, (5) assign actions to an owner other than the case owner, with due date and automatic notification, (6) send and receive emails from within a case, (7) record expenses, (8) attach any sort of electronic document to the case (fax, scanned document, MS Word, etc.).

4 Maintenance – i-Sight provides the ability to perform the following maintenance functions: Add, modify or delete users, select their access level and notify them by email of their username and password, Add, modify or delete category items (issues, products, etc.), Add, modify or delete workflow rules (for example, users may change timing of notifications).

5 Access Controls – Access controls can be configured to restrict functions available to specified user

groups and data available to the user groups, this includes: (1) Case Owner - Create, Assign, Edit Cases, (2) Analyst - (Case Owner Functions) and can view canned reports, (3) Administrator - can do everything including maintenance functions, (4) Report - Access to Ad-hoc reports and all data, (5) View Only - can view all cases and reports. Additionally these functions can be combined with one other parameter to determine what data can be viewed. For example this information could be restricted based on a user’s department. In that case, the user could only see cases and report information related to their cases. Other examples could include case type, location, severity, etc.

6 Reporting – Users will have access to all reporting data through the ad-hoc tool.

Other i-Sight implementation scope considerations:

a) Business Analysis – Our scope includes up to twenty (20) days of business analysis to configure i-Sight to meet West Virginia’s requirements. Our experience has been that twenty days are sufficient to set up i-Sight for a program integrity unit. Additional time will be billed at T&M.

b) Training – Initial training of end-users will be provided by Thomson Reuters on site in Charleston in one (1) class of up seven (7) participants.

c) Data Conversion Not Included – Conversion of legacy data from an existing case management system is not included within the scope of this proposal. However, such services could be provided at an additional cost.

Documents

SEC 10 - Solution Alignment with BMS Business Needs 10 - solution... · SECTION 10 SOLUTION ALIGNMENT WITH BMS’ BUSINESS NEEDS RFP §4.1.10 In Section 10, ... propose will provide