wv hfma conference tuesday october 21, 2014 flatwoods, wv

WV HFMA ConferenceTuesday October 21, 2014

Flatwoods, WV

Meeting Agenda

Introductions

Brief History

Available Products

Department Specialties

Questions and Answers

Health Plan Introductions

Introductions Brad Minton

VP Network Services304-598-3911

Bminton@Healthplan.org

Karen Lavery Provider Relations-Education Coordinator304-598-3911

Klavery@Healthplan.org

The Health PlanHistory

The Health Plan History A 501c-4 not-for-profit corporation,

chartered in West Virginia and domiciled in Ohio (St. Clairsville) in 1979

One of the largest locally managed MCOs in Ohio and West Virginia, serving over 350,000 covered lives

Established and financially secure with over $200 million in reserves

Commercial service area encompasses 76 counties in Ohio and West Virginia

The Health Plan History Regional Expansion 2014 / 2015

17 Counties in SE Ohio, Virginia and Northern Kentucky

National Expansion 2015 Acquiring Licenses in all 50 States

Focus on TPA Services and Government Programs

Regional Partnerships

Mergers and Acquisitions

Available Products

Health Plan Lines of Business Fully Insured Plans (HMO, EPO, POS, PPO), ACA Metal

Plans

Self Funded Plans (HMO, EPO, POS, PPO, THP RE)

Managed Workers’ Compensation Program (Ohio MCO), TPA, Managed Disability, FMLA Administration

PBM Management Capabilities

Vision and Dental Programs

Medicare Products (MAPD, DSNP, Medicare Supplement)

WV Medicaid – Mountain Health Trust

WV PEIA

Membership Breakdown

34,330

25,432

15,825

52,230

Commercial

MedicareAdvantage

Medicaid

Self Funded

Medical Membership by Line of Business

UPSHUR

LEWIS

RANDOLPH

BARBOUR

PLEASANTS

WYOMING

RALEIGH

WOOD RITCHIE

WIRT

WAYNE

BRAXTON

HARRISON

SUMMERSMONROE

MERCER

ROANE

KANAWHA

CLAYPUTNAM

CABELL

PRESTON

WEBSTER

POCAHONTASNICHOLAS

DODDRIDGE

TYLER

MONONGALIAWETZEL

MARSHALL

MINGOLOGAN

MCDOWELL

MASON

JACKSON

LINCOLN

BOONE

GILMER

FAYETTE

GREENBRIER

CALHOUN

BERKELEYMORGAN

JEFFERSON

HANCOCK

OHIO

BROOKE

PENDLETON

TUCKER

HARDY

GRANT

MINERALHAMPSHIRETAYLOR

MARION

Current Service Area

Approved By CMS Enrollment 8-1-14

Application August 2014

OHIO

PENNSYLVANIA

MARYLAND

VIRGINIA

KENTUCKY

HEALTH PLAN Medicaid Service Area August 2014

UPSHUR

LEWIS

RANDOLPH

BARBOUR

PLEASANTS

WYOMING

RALEIGH

WOOD RITCHIE

WIRT

WAYNE

BRAXTON

HARRISON

SUMMERSMONROE

MERCER

ROANE

KANAWHA

CLAYPUTNAM

CABELL

PRESTON

WEBSTER

POCAHONTASNICHOLAS

DODDRIDGE

TYLER

MONONGALIAWETZEL

MARSHALL

MINGOLOGAN

MCDOWELL

MASON

JACKSON

LINCOLN

BOONE

GILMER

FAYETTE

GREENBRIER

CALHOUN

BERKELEYMORGAN

JEFFERSON

HANCOCK

OHIO

BROOKE

PENDLETON

TUCKER

HARDY

GRANT

MINERALHAMPSHIRETAYLOR

MARION

Service Area Prior to ExpansionExpansion 2012Expansion 2014

Expansion 2015

OHIO

PENNSYLVANIA

MARYLAND

VIRGINIA

KENTUCKY

HEALTH PLAN MEDICARE SERVICE AREA

August 2014

Third Party Administration

Services

Customer service, CSF forms

Claims processing and claims payment

Medical management and utilization review

Disease management

Bank reconciliation services

HIPAA certification administration

Proprietary systems

SPD development

COB, subrogation, and fraud investigation

Third Party Administration (TPA) Services

Enrollment meetings and ID cards

Staff medical directors

Staff pharmacists

Staff social worker

Month end report package

Additional services include: stop-loss insurance and COBRA administration

Third Party Administration (TPA) Services

Claims

Claims processed for physicians, facilities, and dental

Strategic partnership with pharmacy and vision vendors allowing claims information to be loaded in our system in a timely manner

6 certified coders, 13 registered nurses, and 32 clinical technicians review claims

Electronic and paper claims accepted with the ability to view all fields instantly at claim review 135,000 claims reviewed a month

85% of claims received are processed by 15 days

100% paperless within 24 hours

Claims

Claims Claims can be assigned daily based on priority,

payment guidelines, or reviewer training/expertise

We review 90% of claims upfront through various custom edits, not “pay and chase”

We have access to secondary networks on a national basis for out-of-network discount negotiations

In-house staff dedicated to COB research, subrogation, and funds recovery

Customer Service

Customer Service All member and provider calls regarding benefits,

claims issues, and eligibility are answered by a ‘live’ person employed and supervised by The Health Plan

Call queues are structured by product line or group

Abandonment rate considered ‘outstanding’ based on industry standards Abandonment Rate for 2014 is 1.65%

(Industry Standard 5%)

Speed of Answer for 2014 is 11 seconds (Industry Standard 30 seconds or higher)

All forms of member contact documented on a “Contact Service Form” in the computer system as they are received and closed when issue is resolved

Customer Service Length of time to resolve issues calculated by system

based on open and close dates

Integrated systems allow customer service staff to view information below to resolve issues quickly: Benefits

Claims History

Correspondence

Eligibility Information

Emails

Dedicated in-house department handles all complaints, appeals, and grievances

1.4% complaints per thousand members per year

Medical Management

Medical Management Utilization Management

14 full time registered nurses with certifications in managed care and care management

Care/Case Management 7 full time registered nurses with certifications in case

management

Disease Management 6 full time registered nurses with certifications in diabetes

education, obstetrics, and advance cardiac life support

Social Work Services 3 full time licensed masters level social workers

Preauthorization of Services

Provides oversight of health care services to members

Ensures services are medically appropriate and promotes access to care in a timely, effective, and efficient manner

Registered nurses help members get the care they need, when they need it, using nationally recognized criteria

Medical directors review any service that does not meet criteria

Hospital Review

Registered nurses receive clinical information from hospitals about member’s care and progress

Monitors quality of care members receive

Assists with discharge planning

Utilization Management

Care/Case Management Care Management – process to assist members in managing their

medical conditions to improve their health status

Registered nurses assist members with ongoing health care needs through regular telephonic contact

Complete comprehensive assessments and establish a care plan with the member and their caregiver

Arrange follow-up to physicians and coordinate services through the sharing of care plans with members and their physicians

Catastrophic Case Management – collaborative process to meet member’s comprehensive health care needs to promote quality, cost effective care

Certified registered nurses in case management that help members to achieve wellness by identifying appropriate providers and available resources

Supports members who have experienced life altering injury or illness such as traumatic brain or spinal cord injury or bone marrow or other solid organ transplant

Serves as the liaison by having direct communications with the member/caregivers, physicians, and providers of service to coordinate care across the continuum

Disease Management Uses nationally recognized evidence-based practice guidelines

for:

Diabetes

Chronic obstructive pulmonary disease (COPD)

Congestive heart failure (CHF)

Prenatal care (high-risk pregnancy)

Supports physician-patient relationship and plan of care through regular telephonic contact

Helps with patient empowerment, self-management, and medication adherence in “Journey for Control” classes, one-on-one educational sessions, and educational material mailings

Emphasizes prevention of exacerbations and complications by educating members with heart failure about weight gain and supplying them with a scale

Social Work Services 3 social workers with hospital, long-term care/rehab, and

community experience

Financial help for medications

Accesses community resources

Provides support and counseling

Other Medical Services Hospital Discharge Follow-up Calls

Registered nurses call members within 48 hours of acute discharge

Assess condition/answer questions

Discuss medications

Assist with follow-up

In-house Nurse Information Line Registered nurses available 24/7

Assist members to urgent or emergent level of care

Assist with out-of-area or emergent care needs

Assist with access to pharmacy or behavioral health benefits

Quality Improvement

External Quality Regulators Responsible for compliance with outside quality

regulators:

National Committee for Quality Assurance (NCQA)

Centers for Medicare & Medicaid Services (CMS and BMS)

Employer groups

Quality standards are applied to ALL Health Plan members regardless of employer group

Healthcare Effectiveness Data and Information Set (HEDIS®)

Clinical practice guidelines

Primary care physician-driven guidelines from nationally recognized sources

Accessibility and availability

Monitoring of a member’s ability to receive services in a timely manner and within reasonable travel distance

Satisfaction of care

Survey driven

Continuity and coordination of care

Quality of care (variances, problems, complaints)

All monitored for compliance to standards. Corrective action plans required when standards not met

Outcomes

Health & Wellness Promotion Telephonic outreach

Encourage members 18 years and older to participate in preventive care

Provides personalized contact with members who are missing important services and/or testing like:

Well care visits and establishing with a PCP

Preventive health services

General and disease-specific discussions

Management of care after an event

Can include any member group

Behavioral Health

Behavioral Health Unit All inclusive unit

Customer Service

Preauthorizations

Utilization Review

Case/Care/Disease Management

Claims Payment

Services directed by evidence-based national guidelines InterQual

Independent Reviewers also use InterQual

Staffed by behavioral health professionals and certified nurses

Provider Network

HP Network Contracted with 113 facilities in primary service area

Contracted with over 14,500 physicians

All contracting and service items (new providers, claims inquiries, questions, etc.) serviced by The Health Plan directly

NCQA Excellent Accreditation

National Network capability through Global Care agreement

Regional and national partnerships providing access to competitive discounts

Provider Network

Tertiary Facilities Include:

Ohio State University

Cleveland Clinic

UPMC Children’s

Allegheny / West Penn

Nationwide Children’s

West Virginia University Hospital

Charleston Area Medical Center

Akron General Medical Center

Children’s Hospital Medical Center of Akron

Information Systems/Web

Information Systems All core systems developed and

maintained in-house allowing for quick modifications/enhancements

Custom core systems include: Care/Case/Disease Management

Claims Adjudication

Enrollment

Medical Utilization

Provider Networking

Plan Design

Information Systems Integrated document imaging system

ties to our core systems and secure web portals

Work with numerous clearinghouses and direct providers to receive HIPAA EDI X12 compliant and noncompliant data formats

All core systems are designed with data and hardware redundancy including a facility-wide generator for 24/7 run-time

SSAE 16/SOC 1 audit performed yearly

Web Capabilities All web portals developed, maintained,

and hosted in-house Website, healthplan.org, features:

Provider search

HRA and other health interactive tools

Information on advance care planning, preventive care, and pharmacy services

Ability to create customized homepages for certain groups

Web Capabilities Secure Member Portal features:

Claims history, dollar and visit limitations

Copay information

Correspondence/EOB

Secure Provider Portal features: Member eligibility and copay amounts

Claim information

Referral information

Secure Enrollment Portal for group administrators

Secure Group and Broker Portal in development for 2014

Established as a community health organization, The Health Plan delivers a clinically driven, technology enhanced, customer-focused platform by developing and implementing products and services that manage and improve the health and well-being of our members. We achieve these results through a team of health care professionals and partners from across our community.

Mission Statement

Thank You

Questions?