connections for increasing revenue payer – provider connect kelly gregg, fhfma, chief financial...
TRANSCRIPT
Connections for Increasing Revenue Payer – Provider Connect
Kelly Gregg, FHFMA, Chief Financial Officer, Diagnostic Clinic, Largo, Florida
Donna Maddox, Product Director, Integrated Care, GE Healthcare IT
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Diagnostic Clinic
• Multi-specialty medical practice with over 100 providers on staff
• Serving over 400,000 patients
• 5 northwest Florida locations – Largo, Countryside, Palm Harbor, and St. Petersburg (2)
• On-site laboratory and imaging services including x-ray, PET, MRI, and CT scan
• Optical shop, audiology, podiatry, interventional spine care and physical therapy
• Walgreen’s pharmacy on-site
H. Charles Cambell, M.D., FACS President and CEOKelly Gregg, FHFMA, Chief Financial OfficerJames F. Rivenbark, III, M.D. Chief Medical and Operations Officer
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Medicare Advantage Members
• Advantage Care Center• Care Coordination – Transition
Services• Value Based Revenue & Quality
Management Department
Services and processes to maximize outcomes both Clinical and Financial
Diagnostic Clinic is engaged in multiple risk and shared savings programs. We have to be nimble and responsive – patients and payers make choices that impact our bottom line.
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Medicare Advantage
• Private plan option accounts for over 30% of all Medicare enrollment. 1
• Payments • CMS adjusts payments to MA plans based risk adjustment factor (RAF) which measures
beneficiaries’ estimated relative costs based on demographics and health characteristics
• Quality Bonus Payments based on Star rating system
1 ASPE Issue Brief, April 2014
Payers have information that can provide insight
for improving clinical quality and financial
outcomes for providers
Physicians are the owners of the clinical care
quality and clinical documentation that are
used to set premium levels for payers in capitated risk
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Discovery
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It’s Complicated and Important
• Extract data from multiple systems
• Transfer to paper check lists and spreadsheets
• Update check lists and spreadsheets
• Data entry into multiple systems
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Florida Blue
• Owned by GuideWell Mutual Holding Company
• 850,000 + enrollees, 42 % market share
• HMO, PPO, and regional PPO Medicare Advantage plans
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Data Exchange
Payer Data • Medicare Advantage members
attributed to the provider organization
• Patient Care Summaryo Gaps in Care codifiedo Diagnosis
• Diagnosis codes by member that have not been submitted in claims in the current calendar year (for HCC)
• Member suspected diagnosis• Members expected and not
completed quality codes ( Gaps in Care )
• ADT data from BayCare
Provider Data • Service-based claims (already happens
today)• Member Gap in Care resolutions (eg.
service rendered, not medically relevant, etc.)
• Member HCC resolutions (eg. diagnosis code, no longer medically relevant)
• Members Quality Code resolutions• Member CCDAs (can include lab data)
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Integrate Critical Information in Provider Workflow
• ICD 9 association with HCC, visible in all work flow
• Problem list ( diagnosis) reconciliation
• Quality indicators codified including resolution
• Coder support for quality reporting
• Transition of care management
• Patient and provider population metrics displayed in dashboard
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Proof of Concept Demonstration
Proprietary and confidential. Proof of Concept – Not a current offering or product. Concept shown represents ongoing product research and development efforts. These research and development efforts are not products and may never become products. Not for sale.
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Questions
