slide1 n.
Download
Skip this Video
Download Presentation
North Jersey IIA Software Expo Data Mining-driven Eligibility, Dependent Eligibility and Claims Auditing May 17, 2007

Loading in 2 Seconds...

play fullscreen
1 / 16

North Jersey IIA Software Expo Data Mining-driven Eligibility, Dependent Eligibility and Claims Auditing May 17, 2007 - PowerPoint PPT Presentation


  • 104 Views
  • Uploaded on

North Jersey IIA Software Expo Data Mining-driven Eligibility, Dependent Eligibility and Claims Auditing May 17, 2007. Contents. Introductions and Overview The Business Case Audit Survey Responses and Case Studies Web-based Technology Next Steps. Introductions and Overview.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'North Jersey IIA Software Expo Data Mining-driven Eligibility, Dependent Eligibility and Claims Auditing May 17, 2007' - mya


Download Now An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
slide1

North Jersey IIA

Software Expo

Data Mining-driven

Eligibility, Dependent Eligibility and Claims Auditing

May 17, 2007

slide2

Contents

  • Introductions and Overview
  • The Business Case
  • Audit Survey Responses and Case Studies
  • Web-based Technology
  • Next Steps
slide3

Introductions and Overview

Web: Eligibility Auditing

Case Management Audit

Dependent Audit

Clinical and Disease Management Audit

DIFFERENTIATORS

Medical Claims

  • Comprehensive
  • ROI-driven
  • Independent
  • 100% Data
  • Data Mining
  • Root Cause
  • Passion

Rx Claims

Eligibility

2007

2006

2005

2004

2003

2002

2001

slide4

Introductions and Overview -

Technology Model

SPDs, ASO

Contracts and

Reports

Census

Rx

Enrollment

COBRA

Medical

Cleanse

  • Business/Audit Needs:
  • Eligibility
  • Dependent Eligibility
  • Subrogation
  • Discounts
  • Financial
  • Limits
  • Exclusions
  • Rx rebates
  • Other

Load

Member

Data Warehouse

Query

Reports

Suspects

slide5

The Business Case

* Excludes recoveries from payor

** Includes a 2% reduction in spend plus a 10% trend

*** Includes a 3% reduction in spend plus a 10% trend

slide6

Survey Responses and Case Studies –

Why Perform an Audit?

RESPONSE EXAMPLE

  • #1 – Recapture overpayments ESRD Medicare
  • #2 – Contain future costs Point-in-time Eligibility
  • #3 – Identify root cause improvements Subrogation
  • #4 – Contribute to vendor negotiations
  • #5 – Perform due diligence
slide7

Survey Responses and Case Studies –

Which Medical Areas Should Be Audited?

RESPONSE EXAMPLE

  • #1 – Discounts (consistent across all responses) N/W Discounts & Access Fees
  • #2 – Limits and exclusions Gastric Bypass
  • #3 – Stop loss Plan Year Straddle
  • #4 – Member liability
  • # 5- Employee eligibility Low Hours
  • #9 – Subrogation and coordination of benefits
slide8

Survey Responses and Case Studies –

Which Rx Areas Should Be Audited?

RESPONSE EXAMPLE

  • #1 – Limits and exclusions Biotech
  • #2 – Discounts AWP – Marketing Vs. Contract
  • #3 – Rebates Contract – In/Out
  • #4 – Member Liability Systemic Co-payment
  • #5 – Stop Loss
slide9

Survey Responses and Case Studies –

What Are The Top Attributes?

  • RESPONSE FACT
  • #1 – Data Warehousing Technology Data Mining/web
  • #2 – Specific Payor Experience National Payors/PBMS
  • #3 – Cost
  • #4 – Performance Guarantees 100% ROI +
  • #5 – Return On Investment Several Hundred %
slide10

Web-Based Technology:

Eligibility Dashboard Example

Plan statistics as well as query summaries are provided in the Dashboard Summary

Users can refine the standard query selection criteria by changing the search criteria

The query result can be easily downloaded to Excel for further analysis

slide11

Web-Based Technology:

Beyond Termination Example

In this example we looked for claims greater than $200 and term dates after Sept. 1, 2005

slide12

Web-Based Technology:

Low Premium Example

This query identifies tier mismatch suspects

slide13

Web-Based Technology:

Dependent Confirmation Web Page

Employees are presented their dependents and are asked to confirm eligibility

Alternatively, employees can be prompted with “fill-in-the blank” questions regarding their dependents

Employees can be asked questions about spousal employment and their respective benefits insurance or questions regarding their college age child to ensure eligibility

slide14

Web-Based Technology:

Dependent Audit Dashboard - 24/7 ROI

Member activity metrics are available

24/7 via the web

The actual savings based upon claim

spend is available 24/7 via the web. Savings

Also be computed on a per-capita basis

The actual savings by relationship

type is available 24/7 via the web

slide15

Web-Based Technology:

Departmental Healthcare Spending

Our system also helps users understand member spend by organizational unit

slide16

Next Steps

  • Stop by our booth
  • Ask us about potential leakage in your plan
  • Contact

Howie Gerver at 201.891.8010 or, Howie@HRBestPractices.com; or

Ed McDermott at 201.818.9196 or Emcdermott@HealthCostSolutions.biz

  • Thank you for your time and interest!