Perfect Perfect ClarityClarity

Meeting Your Clinical and Meeting Your Clinical and Information Technology NeedsInformation Technology Needs

FOCUS Behavioral FOCUS Behavioral HealthHealth

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BEHAVIORAL HEALTHBEHAVIORAL HEALTHFounded 1994Founded 1994

FOCUS is a Behavioral Review Organization located FOCUS is a Behavioral Review Organization located in in St. Petersburg Florida which provides MD and St. Petersburg Florida which provides MD and clinician reviews for major insurers and MBHOsclinician reviews for major insurers and MBHOs

We have Psychiatrists and non-MD clinicians on our We have Psychiatrists and non-MD clinicians on our panel of experienced reviewerspanel of experienced reviewers

We conduct business through a proprietary clinical We conduct business through a proprietary clinical system our clients access through a secure web-system our clients access through a secure web-based portalbased portal

FOCUS can modify its reviews to include client FOCUS can modify its reviews to include client specific level of care guidelines, customized specific level of care guidelines, customized workflows and reportingworkflows and reporting

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Founded 2004Founded 2004

Perfect Clarity is another line of Perfect Clarity is another line of business for FOCUS BHbusiness for FOCUS BH

It specializes in consulting and It specializes in consulting and development of customized process development of customized process management systems for health care management systems for health care organizationsorganizations

It provides or coordinates development It provides or coordinates development and hosting of multi-platform relational and hosting of multi-platform relational database solutionsdatabase solutions

Perfect Clarity concurrently manages all Perfect Clarity concurrently manages all IT solutions for FOCUS and is engaged in IT solutions for FOCUS and is engaged in the automation of national MBHO firms.the automation of national MBHO firms.

OVERVIEWOVERVIEW

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BehavioraBehaviorall

ReviewsReviews

ClientClientAutomatioAutomatio

nn

CareCareManagemeManageme

ntnt

FOCUS + PERFECT CLARITYFOCUS + PERFECT CLARITY

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AgendaAgenda

FBH/PC - Who We AreFBH/PC - Who We Are

Data Analytics: Driving the BusinessData Analytics: Driving the Business

Organizational Considerations Organizational Considerations

Using Data to Manage UtilizationUsing Data to Manage Utilization

Client and Market Success StoriesClient and Market Success Stories

Conclusion and DiscussionConclusion and Discussion

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Data Analytic ThemesData Analytic Themes

How companies organize their data analytic How companies organize their data analytic functionsfunctions

The types of data used to manage utilizationThe types of data used to manage utilization

For what functions and analyses is this data For what functions and analyses is this data usedused

Give examples of problems and solutions facing Give examples of problems and solutions facing businesses todaybusinesses today

Common MBHO & EAP QuestionsCommon MBHO & EAP Questions

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Organizational Organizational ConsiderationsConsiderations

1. Key concern: centralized vs distributed data 1. Key concern: centralized vs distributed data managementmanagement

2. Most MBHOs have centralized data warehouses 2. Most MBHOs have centralized data warehouses with input from multiple UM/Claims/Eligibility systems with input from multiple UM/Claims/Eligibility systems feedsfeeds

Advantages: standardized reporting used by Advantages: standardized reporting used by multiple depts / ‘scrubbed data’ / multiple depts / ‘scrubbed data’ / tasks built around this datatasks built around this data

Disadvantages: little flexibility for end-Disadvantages: little flexibility for end-users / system downtime domino effect / users / system downtime domino effect / complex QI processescomplex QI processes

3. End-users still require own data ‘experts’ to 3. End-users still require own data ‘experts’ to access, set report parameters, QA and generate access, set report parameters, QA and generate ad-hoc reportsad-hoc reports

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1. As a result, many companies use a combination of 1. As a result, many companies use a combination of approaches-dedicated corporate data analytics approaches-dedicated corporate data analytics departments and data analysts in field / regional departments and data analysts in field / regional offices:offices:

1 DA can support a large regional operation-1 DA can support a large regional operation-usually reports to local executive, but can usually reports to local executive, but can have dotted-line to corporate departmenthave dotted-line to corporate department

Corporate DA department size will vary - Corporate DA department size will vary - estimate 5-10 FTEs will report to CIO / Chief estimate 5-10 FTEs will report to CIO / Chief Clinical Officer for a large organizationClinical Officer for a large organization

Organizational Organizational ConsiderationsConsiderations

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Organizational Organizational ConsiderationsConsiderations1. Common practice - develop local ‘one-off’ DBs to 1. Common practice - develop local ‘one-off’ DBs to

support UM processsupport UM process

Allows more timely ad-hoc analysis of acute Allows more timely ad-hoc analysis of acute care utilization datacare utilization data

Tracking of local program initiatives - how Tracking of local program initiatives - how many IP diversions from admissions requestsmany IP diversions from admissions requests

Data doesn’t match centralized UM data, but Data doesn’t match centralized UM data, but should be close enough to be usefulshould be close enough to be useful

IP days measured in month of admit or IP days measured in month of admit or dischargedischarge

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Data Used to Data Used to Manage Utilization Manage Utilization TrendTrend

1. Primary Data Streams1. Primary Data Streams

Member Tape Loads - Eligibility AccuracyMember Tape Loads - Eligibility Accuracy

Encounter DataEncounter Data

Claims AdjudicationClaims Adjudication

Verify billed vs. paid vs. acutalVerify billed vs. paid vs. acutal

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Data Used in Data Used in Analyzing Analyzing Utilization TrendUtilization Trend

1. Ancillary Data Streams1. Ancillary Data Streams

Medical/Surgical Encounter Data Medical/Surgical Encounter Data

Workers CompensationWorkers Compensation

Disability DataDisability Data

Pharmaceutical ClaimsPharmaceutical Claims

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Data Used to Data Used to Manage Utilization Manage Utilization TrendTrendProviders and Facility NetworksProviders and Facility Networks

Facility ScorecardFacility Scorecard

Provider profiling (using auth or claims data)Provider profiling (using auth or claims data)

Frequency of accommodations for OON facsFrequency of accommodations for OON facs

Key claims based metrics allows Key claims based metrics allows comparisons between facilitiescomparisons between facilities

Facility ALOS / discharge appts / Facility ALOS / discharge appts / comparative datacomparative data

Attending MDs utilization - no. of cases / Attending MDs utilization - no. of cases / ALOSALOSFrequency and outcomes of clinical appealsFrequency and outcomes of clinical appeals

Compliance with precertification and LOC protocolsCompliance with precertification and LOC protocols

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Data Used to Data Used to Manage Utilization Manage Utilization TrendTrendCare ManagementCare Management

Staffing ratios vs. actual FTEsStaffing ratios vs. actual FTEs

Case load analysisCase load analysis

Care Managers and Medical Director relationship - Care Managers and Medical Director relationship - IRRIRR

ALOSALOSMembershipMembership

Review member mix - MC Dual Eligibles and MC Review member mix - MC Dual Eligibles and MC AdvantageAdvantage

HP expansion into new geographic areas or new HP expansion into new geographic areas or new lineslines

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Data Used to Data Used to Manage Utilization Manage Utilization TrendTrendEmployee Assistance ProgramEmployee Assistance Program

1. Penetration rate1. Penetration rate

% Membership using EAP. Definition is % Membership using EAP. Definition is important.important.2. Members referred to non-benefit resources2. Members referred to non-benefit resources

3. Members referred to MHSA benefits3. Members referred to MHSA benefits

4. Gatekeeper model4. Gatekeeper model

% of EAP referrals using MHSA% of EAP referrals using MHSA5. Website page viewing analysis5. Website page viewing analysis

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F PC R H

FOCUS Client AFOCUS Client A

Presenting Problem:Presenting Problem:

Client/Market SuccessesClient/Market Successes

Decentralized data modelDecentralized data model

Minimal use of relational data architectureMinimal use of relational data architecture

Primitive organization of Word & Excel Primitive organization of Word & Excel documentsdocuments

No web portal for remote officesNo web portal for remote offices

Poorly documented policies & proceduresPoorly documented policies & procedures

Difficulties with QADifficulties with QA

Inconsistent & inaccurate use of industry Inconsistent & inaccurate use of industry terminologyterminology

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FOCUS Client AFOCUS Client A

SolutionSolution

Client/Market SuccessesClient/Market Successes

Consultative review of all business needsConsultative review of all business needs

Development of software prototypeDevelopment of software prototype

Cycle of presentation, modification and Cycle of presentation, modification and re-presentation until acquisition of company re-presentation until acquisition of company approvalapproval

Development of Customized Data Management Development of Customized Data Management SystemSystem

Presentation, final edits and signoff by Presentation, final edits and signoff by managementmanagement

Implementation, training and ongoing Implementation, training and ongoing improvementimprovement

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FOCUS Client AFOCUS Client A

ResolutionResolution

Client/Market SuccessesClient/Market Successes

Centralized data repository provides enhanced Centralized data repository provides enhanced security, HIPAA compliance & automated security, HIPAA compliance & automated quality controlsquality controls

Auditing and QA greatly enhancedAuditing and QA greatly enhanced

All offices participate in real-time data All offices participate in real-time data environmentenvironment

Remote/home based employee model now Remote/home based employee model now feasiblefeasible

Accurate and up-to-the minute reportingAccurate and up-to-the minute reporting

Data mining provide analysts multiple Data mining provide analysts multiple perspectivesperspectives

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Wellcare RationaleWellcare Rationale

Presenting Problem:Presenting Problem:

Client/Market SuccessesClient/Market Successes

Utilizing InterQual™ criteria with a Utilizing InterQual™ criteria with a combination of Medicare, Medicaid and combination of Medicare, Medicaid and commercial plans, rationale verbiage commercial plans, rationale verbiage submitted by Physician Advisors was often submitted by Physician Advisors was often out of compliance due to the multitude of out of compliance due to the multitude of combinations and complex plan combinations and complex plan requirements.requirements.

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Wellcare Rationale Wellcare Rationale GeneratorGeneratorSolution & ResolutionSolution & Resolution

Client/Market Client/Market SuccessesSuccesses

Organization of rationale components into 3 Organization of rationale components into 3 segments:segments:

PreamblePreamble

Application of InterQual™ CriteriaApplication of InterQual™ Criteria

SuffixSuffix

System now auto-generates compliant System now auto-generates compliant rationales and allows Physician Advisor to rationales and allows Physician Advisor to customize finalized documentationcustomize finalized documentation

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DemonstrationDemonstration

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Perfect Perfect ClarityClarity

Meeting Your Clinical and Meeting Your Clinical and Information Technology NeedsInformation Technology Needs

FOCUS Behavioral FOCUS Behavioral HealthHealth

Thank YouThank You

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