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Information Innovation People’s Choice Award. Karen L. LaJaunie. Blue Cross and Blue Shield of Kansas City . September 24, 1:45 p.m. Tennessee Ballroom . Purpose.

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Information Innovation People’s Choice Award


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    1. Information InnovationPeople’s Choice Award Karen L. LaJaunie Blue Cross and Blue Shield of Kansas City September 24, 1:45 p.m. Tennessee Ballroom

    2. Purpose • The IM Symposium “Peoples Choice” Information Innovation Award is designed to recognize those Blue’s Plans and their subsidiaries, who have achieved significant business value or innovation in a proven information-based solution while advancing the Charter of the IM Symposium. Overall, our most valuable goal is to share insights learned among our Blues IM colleagues while recognizing the value our Plans are delivering to the Healthcare industry through innovative information solutions.

    3. Award Selection Process • Request for Submissions • Email & Website request for Submissions • Finalists • A selection committee comprised of four IM Symposium Board Members objectively reviewed & scored each submission against our selection criteria. • Top three submissions by points became finalists. • No board member whose plan submitted for this award participated in the scoring of the submissions • The Award Chairman was not a voting member • People’s Choice • Winner voted BY YOU during the Symposium

    4. Awards Gold: 1st Place, Most IM Symposium Votes Silver: 2nd Placein total # of votes Bronze: 3RD Placein total # of votes Gold, Silver, and Bronze winners are awarded an IM Symposium Information Innovation Medal and Trophy.

    5. 2012 IM Symposium Information Innovation People’s Choice Award 2012Award Submissions

    6. 2012 Award Submissions (In order of receipt) • Member Centric Decision Management (MCDM) Process - BCBSTN • Patient Centered Medical Home Reporting – Impacting Provider Performance and Enhancing Consumer Engagement - BCBSTN • Member Dashboard - BCBSTN

    7. 2012 Award Submissions (In order of receipt) • Clinical Data Mart and Financial and Clinical Insights Report: A Member Centric Approach to Reporting and Analytics - BCBSTN • Member Migration in an Exchange World - HCSC

    8. 2012 Award Submissions (In order of receipt) • Master Person Index (MPI) - BCBSTN • Achieving Regulatory Compliance through Standardized Enterprise Appeals Process and Analytic Application – HCSC

    9. 2012 IM Symposium Information Innovation People’s Choice Award 2012AwardFinalists

    10. 2012 IM Symposium Information Innovation People’s Choice Award Member Centric Decision Management (MCDM) Process BCBSTN Stephen Jones, PhD Senior Research Scientist Eric Chandler, Manager, Reporting and Analytics Heather Jenkins, Systems Analyst

    11. 2012 IM Symposium Information Innovation People’s Choice Award Achieving Regulatory Compliance through Standardized Enterprise Appeals Process and Analytic ApplicationHCSC Li-Li Huang, Sr. Director, Informatics Application Management Kyle Gearhart, Sr. Director, National Account Service Delivery Organization

    12. 2012 IM Symposium Information Innovation People’s Choice Award Patient Centered Medical Home Reporting – Impacting Provider Performance and Enhancing Consumer Engagement BCBSTN Kevin N. Raynor, FAHM, HMP, MBA, Manager, Provider Performance Management Joshua Bell, MBA Data Architect Team Lead, Medical Informatics

    13. How to Decide? • Each Finalist will be provided 20 minutes to present their submission • Each Attendee of the Symposium will be requested to submit one and only one vote • Plans with multiple attendees each get a vote • Vendors are not allowed to vote • Any ballot that does not have a name and a vote selection will be discarded

    14. Finalists Presentations • BCBSTN - Member Centric Decision Management (MCDM) Process • Stephen Jones, PhD, Senior Research Scientist • Eric Chandler, Manager, Reporting and Analytics • Heather Jenkins, Systems Analyst • HCSC - Achieving Regulatory Compliance through Standardized Enterprise Appeals Process and Analytic Application • Li-Li Huang, Sr. Director, Informatics Application Management • Kyle Gearhart, Sr. Director, National Account Service Delivery Organization • BCBSTN - Patient Centered Medical Home Reporting – Impacting Provider Performance and Enhancing Consumer Engagement • Kevin N. Raynor, FAHM, HMP, MBA, Manager, Provider Performance Management • Joshua Bell, MBA, Data Architect Team Lead, Medical Informatics

    15. Member Centric Decision Management Reaching the RightPersontheRightWaywith the RightMessageat the RightTime Eric Chandler, Heather Jenkins & Stephen Jones BlueCross BlueShield of Tennessee

    16. Eric Chandler Manager, Reporting and Analytics – Commercial Business at BlueCross BlueShield of Tennessee. Mr. Chandler completed his studies in Management at Covenant College. Eric has over 18 years experience in the insurance industry in health and financial analytics as well as health information technology. Eric’s work at Blue Cross Blue Shield of Tennessee has focused on bridging the gap in patient and provider information leveraging technological solutions and improving health outcomes through better communications. Heather Jenkins Systems analyst in Information Management – Health Informatics at BlueCross BlueShield of Tennessee, with 16 years of experience providing effective technological solutions for financial and health information initiatives.  Heather leads the Decision Support Analytics & Quality Management team in support of Predictive Analytics and HEDIS certification software at BlueCross BlueShield of Tennessee.  Heather received a BS in Management Information Systems at The University of Alabama. Dr. Stephen Jones is the senior research scientist for predictive analytics at BlueCross BlueShield of Tennessee, focusing on research and analytic efforts in population health management.  Some of his work includes spatio-temporal modeling of infectious diseases, building proactive disease identification and decision support models for care management programs, enhancing disease surveillance activities through the use of administrative data, assessing the long-term impacts of food and water borne enteric infections, and utilizing geo-spatial analytics to strategically prioritize outreach efforts to support improved health outcomes.  He received a BS in biology and art history from Wofford College, and a MS and PhD in biology from Clemson University.  His post-doctoral research was in spatial epidemiology with the Department of Population Medicine at Harvard Medical School.

    17. The Problem

    18. Our Solution mem·ber : noun - a person that is part of a society, party, group, or other body. cen·tric: adjective - pertaining to or situated at the center; central. The more we know, the greater potential we have for a meaningful communication.

    19. Our Solution mem·ber : noun - a person that is part of a society, party, group, or other body. cen·tric: adjective - pertaining to or situated at the center; central. The more we know, the greater potential we have for a meaningful communication.

    20. We must know about our members…

    21. …well enough to know they aren’t all the same

    22. Knowing only half of the story Clinical Profile • Jackie, Age 54 • Diabetes • Frequent Usage of the ER • Non-Compliant with Meds • BMI > 35 • No Established PCP • Janice, Age 54 • Diabetes • Frequent Usage of the ER • Non-Compliant with Meds • BMI > 35 • No Established PCP

    23. Knowing the whole story Clinical Profile • Jackie, Age 54 • Diabetes • Frequent Usage of the ER • Non-Compliant with Meds • BMI > 35 • No Established PCP • Janice, Age 54 • Diabetes • Frequent Usage of the ER • Non-Compliant with Meds • BMI > 35 • No Established PCP • Janice, Age 54 • Struggling Society Segment • Economically challenged • Unemployed • No access to computers • Transient Lifestyle Segment • Jackie, Age 54 • Suburban Style segment • Established residence • Family-centric living • Internet savvy • Employed

    24. Making it Happen • Teamwork & Collaboration • Multiple IT & business areas involved • Creativity & Flexibility • Multiple technologies interacting together • Vendor Management • Integration with multiple vendors into a streamlined process

    25. MCDM Process Data Identification / Stratification Content Management Outreach Delivery IT/Data Integration Medical Informatics Marketing/Communications IT, Print Solutions, Consumer Advisors Reactive Proactive ODMT (Outreach Delivery Management Tool) Prioritization/ Optimization

    26. Outreach View for Consumer Advisors

    27. The Medicaid Population – Lifestyle Profile M – Families in Motion Younger, working-class families with diverse adult and children household dynamics N – Pastoral Pride Eclectic mix of lower middle-class widowed and divorced individuals and couples who have settled in country and small town areas O – Singles and Starters Young singles starting out, and some starter families, in diverse urban communities R – Aspirational Fusion Multi-cultural, low-income singles and single parents living in urban locations and striving to make a better life S – Struggling Societies Economically challenged mix of singles, divorced and widowed individuals in smaller cities and urban areas looking to make ends meet

    28. Results of a 2012 Diabetes Call Campaign • Top 5 Medicaid segments: • Not very reachable • Not very impactible • Recommendation: Improve ability to contact members via phone, and consider different outreach modality, particularly for N & S (more rural segments)

    29. The Outcome Reach the Right Person Outreach Delivery The Right Way With the Right Message At the Right Time

    30. Q & A

    31. Finalists Presentations • BCBSTN - Member Centric Decision Management (MCDM) Process • Stephen Jones, PhD, Senior Research Scientist • Eric Chandler, Manager, Reporting and Analytics • Heather Jenkins, Systems Analyst • HCSC - Achieving Regulatory Compliance through Standardized Enterprise Appeals Process and Analytic Application • Li-Li Huang, Sr. Director, Informatics Application Management • Kyle Gearhart, Sr. Director, National Account Service Delivery Organization • BCBSTN - Patient Centered Medical Home Reporting – Impacting Provider Performance and Enhancing Consumer Engagement • Kevin N. Raynor, FAHM, HMP, MBA, Manager, Provider Performance Management • Joshua Bell, MBA, Data Architect Team Lead, Medical Informatics

    32. Achieving Regulatory Compliance through Standardized Enterprise Appeals Process & Analytic Application Cathy McClain-Gordon, Sr. Director-HCM Traci Adcock, Sr. Director - SDO Li-Li Huang, Sr. Director-ITG HealthCare Service Corporation (HCSC) September 24, 2:20 p.m. Tennessee Ballroom

    33. Cathy McClain-Gordon Sr. Director- HCM Health Care Service Corporation (HCSC) 312.653.4998 gordonc@bcbsil.com

    34. Traci Adcock Sr. Director- SDO Health Care Service Corporation (HCSC) 972-766-4111 Traci_adcock@bcbstx.com

    35. Li-Li Huang Sr. Director- ITG/TIS HealthCare Service Corporation (HCSC) 972.644.5204 Li-Li_Huang@BCBSTX.com

    36. Achieving Regulatory Compliance through Standardized Enterprise Appeals Process & Analytic ApplicationAgenda • Compliance- What is it? • Attaining Compliance- Why is it difficult? • Our Solution- The Plan for Winning the Game. • Sustaining Our Record. • Governance • Next Steps • Conclusion

    37. Achieving Regulatory Compliance through Standardized Enterprise Appeals Process & Analytic Application Compliance- What is it? An appeal means an oral or written request for review or reconsideration expressing dissatisfaction or disagreement with an adverse benefit/coverage, clinical or administrative determination by HCSC. • Indicators that a request constitutes an appeal include any of the following: • Requests review of an adverse benefit determination or other action taken by HCSC. This may be evidenced by (among other things) the use of the words “appeal”, “review”, “reconsideration” or “complaint” by a member, provider or member’s authorized representative; • The request is mailed to an address that HCSC has designated for appeals (below); • If member /provider or member’s authorized representative calls and specifically requests an appeal; • Resolution of the issue raised requires a review of a prior clinical determination; • Member’s Authorized Representative MUST submit a completed and signed authorization form in order to represent the member. This form must have the following information and be on file at HCSC prior to initiating an appeal; • Member’s acknowledgement authorizing the representative to appeal on his/her behalf with the Member’s signature • Claim number(s) • Dates of service • Provider name • Provider number or • Billed amount

    38. Achieving Regulatory Compliance through Standardized Enterprise Appeals Process & Analytic ApplicationAttaining Compliance- Why is it difficult? • Environment is Challenging- Where Do You Look? • Multiple State Definition- Do we all play the game the same? • Requirements / Standards- Are there any pre-conditions? • Variations in the Business Process- Does everyone play by the same rules? • Everyone Aligned? Were people signing up to play but dropped out when they did not win? It resembled the “childhood game” Hide and Seek

    39. Achieving Regulatory Compliance through Standardized Enterprise Appeals Process & Analytic Application Attaining Compliance- Why is it difficult? MRU Illinois UM Grievance MRU Grievance Grievance MRU FSUs Member CS Behavioral Health Medical Directors Medical Directors Hallmark UM Medical Directors Members Medical Directors Triage Pharmacy Pharmacy Pharmacy Pharmacy Accounts Oklahoma UM Accounts Accounts Mailroom Accounts IL Appeals Appeals Appeals Prime Network Network Network Texas Appeals Network New Mexico UM Providers Hallmark NM Appeals Exec Inquiries PASS Texas UM EAA was developed to improve the overall appeal process, cycle time, increase accuracy and assure regulatory compliance.

    40. Achieving Regulatory Compliance through Standardized Enterprise Appeals Process & Analytic Application Our Solution- The Plan for Winning the Game. Standardized Enterprise Appeals Processing & Analytic Application APPEAL CORRESPONDENCE / LETTER GENERATION FSUs Member CS Medical Directors Hallmark IL HCM Triage DASHBOARD Medical Directors Oklahoma Members TX HCM Mailroom Communication Channel New Mexico Medical Directors OK HCM Texas Providers IMAGE / ECM Medical Directors NM HCM PASS Illinois APPEAL CORRESPONDENCE / LETTER GENERATION Scalability, Accountability and Work Load Balancing Standard Reporting and Analytics, Compliance and Service Levels Continuous Quality Improvements

    41. Achieving Regulatory Compliance through Standardized Enterprise Appeals Process & Analytic Application Our Solution- The Plan for Winning the Game. • The Appeals Project Team utilized an iterative development and deployment methodology. • The following business efficiencies have been realized: • Entry points were reduced to a single point of entry. All incoming appeals are contained within one application. • Cycle time from receipt to close or route improved from 10% within seven days to over 90%. • Standardized appeals terminology and processes were implemented across the enterprise. • Analytic capabilities enable quick process decision-making and the ability to proactively monitor adherence to compliance deadlines. • Implemented a letter generation system specifically tailored for improving correspondence quality (presentation of custom arrangements, contact information). • 100% compliance achieved for expedited appeals in Behavioral Health

    42. Achieving Regulatory Compliance through Standardized Enterprise Appeals Process & Analytic Application Our Solution- The Plan for Winning the Game Key Features and Services Supporting Compliance Attainment • Opens an appeal from various points of integration • Assigns a unique identifier to track each appeal throughout the entire appeal workflow. • Tracks and links multiple levels of appeals based on the original • Assigns service level due dates to each appeal to manage cycle-time and compliance standards. • Provides the ability to initiate an appeal via Siebel Dashboard. • Provides access to appeal information in real time (Local and BlueCard) for significantly enhanced customer service. • Supports all user activities across the enterprise appeals supply chain including member, provider, health care management, and Medical Directors (medical and Behavioral Health).

    43. Achieving Regulatory Compliance through Standardized Enterprise Appeals Process & Analytic Application Enterprise Appeals Analytic Application- Entry Point

    44. Achieving Regulatory Compliance through Standardized Enterprise Appeals Process & Analytic ApplicationAppeal Association [ lvl 1 – lvl 2]

    45. Achieving Regulatory Compliance through Standardized Enterprise Appeals Process & Analytic ApplicationSiebel Dashboard Integration • EAA integrates with our enterprise inquiry documentation tool, Siebel Dashboard. • Request Appeals – users are able to request an appeal in Dashboard and the initial • appeal record is created in EAA • Appeals Summary – Dashboard users are able to see a real-time feed of items in • EAA allowing Customer Advocates the ability to provide appeal status to our members and providers.

    46. Achieving Regulatory Compliance through Standardized Enterprise Appeals Process & Analytic ApplicationDocument Management

    47. Achieving Regulatory Compliance through Standardized Enterprise Appeal Process & Analytic ApplicationLetter Generation

    48. Achieving Regulatory Compliance through Standardized Enterprise Appeal Process & Analytic ApplicationRegulatory Compliance Rule Engine (a) Internal Review which includes: Standard and Expedited (For all Regulation Categories) (b) External Review which includes:Standard and Expedited (For Regulation Categories = ACA and DOI. For all other Regulation Categories, this section will be displayed, but disabled.)* To edit row values, use the dropdown list and/or enter data (in the text field) where necessary – all enabled fields are editable* Once complete, click “save” to commit changes* To delete a rule:(a) Select the “checkbox” next to each row - the row will then become disabled(b) *Once verified, click “delete” to commit changes and remove all affected rows Subcategory Single selection, can be blank * Pre-Service* Post-Service* Provider Plan to Plan Category Single selection, can be blank * Clinical* Non-Clinical Offset Value User entered, required Offset Unit Single selection, required * Calendar Days* Business Days* Hours * State Calendar Days Base Field Single selection, required * Corporate Receive Date (all)* Written Determination Notification Completion Date (all)* Verbal Notification Completion Date (Expedited Internal only)* Documents Provided to IRO (for IER only)* IRO Determination Receipt Date (IER only) Appeal Type Single selection, can be blank * Member * Member Auth Rep* Provider

    49. Achieving Regulatory Compliance through Standardized Enterprise Appeal Process & Analytic ApplicationOur Solution- Analytics and Reporting • Appeals Analytics and Reporting Suite enable accurate and quick decision making in the processing of appeals. The Cognos real-time reporting suite provides all stakeholders access to essential metrics at the enterprise and unit level such as: • Inventory analytics (receipts, work in progress, work completion, and work escalation) • Cycle time analytics • Medical policy analytics • Appeals Reason Code analytics • Quality and productivity analytics • Compliance Adherence • Executive Dashboard • Ad-hoc reporting capability

    50. Achieving Regulatory Compliance through Standardized Enterprise Appeals Process & Analytic ApplicationExecutive Dashboard- Open Inventory * Open appeals within 0-5 days at risk of missing corporate compliance CT = 196 of 1347 (14.5%)