Transcript The Health Plan - West Virginia Healthcare Financial Management

WV HFMA Conference
Tuesday 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 Services
304-598-3911
[email protected]

Karen Lavery
Provider Relations-Education Coordinator
304-598-3911
[email protected]
The Health Plan
History
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
25,432
Medical Membership
by Line of Business
34,330
Commercial
Medicare
Advantage
Medicaid
Self Funded
52,230
15,825
HEALTH PLAN
Medicaid Service Area
August 2014
HANCOCK
BROOKE
OHIO
PENNSYLVANIA
MARSHALL
OHIO
MARYLAND
MONONGALIA
WETZEL
MORGAN
MARION
TYLER
PRESTON
HARRISON
PLEASANTS
MINERAL
TAYLOR
HAMPSHIRE
BERKELEY
JEFFERSON
DODDRIDGE
WOOD
RITCHIE
BARBOUR
TUCKER
GRANT
HARDY
WIRT
CALHOUN
JACKSON
LEWIS
GILMER
UPSHUR
MASON
RANDOLPH
ROANE
BRAXTON
PENDLETON
PUTNAM
WEBSTER
CLAY
CABELL
VIRGINIA
KANAWHA
NICHOLAS
POCAHONTAS
WAYNE
LINCOLN
BOONE
Current Service Area
FAYETTE
GREENBRIER
MINGO
LOGAN
RALEIGH
SUMMERS
MONROE
WYOMING
KENTUCKY
Approved By CMS
Enrollment 8-1-14
MERCER
MCDOWELL
Application August
2014
HEALTH PLAN MEDICARE
SERVICE AREA
HANCOCK
BROOKE
August 2014
OHIO
PENNSYLVANIA
MARSHALL
OHIO
MARYLAND
MONONGALIA
WETZEL
MORGAN
MARION
TYLER
PRESTON
HARRISON
PLEASANTS
MINERAL
TAYLOR
HAMPSHIRE
BERKELEY
JEFFERSON
DODDRIDGE
WOOD
RITCHIE
BARBOUR
TUCKER
GRANT
HARDY
WIRT
LEWIS
GILMER
UPSHUR
CALHOUN
JACKSON
MASON
RANDOLPH
ROANE
BRAXTON
PENDLETON
PUTNAM
WEBSTER
CLAY
CABELL
VIRGINIA
KANAWHA
NICHOLAS
POCAHONTAS
WAYNE
LINCOLN
BOONE
FAYETTE
GREENBRIER
MINGO
LOGAN
RALEIGH
SUMMERS
MONROE
WYOMING
KENTUCKY
MERCER
MCDOWELL
Service Area Prior to
Expansion
Expansion 2012
Expansion 2014
Expansion 2015
Third Party
Administration
Services
Third Party Administration
(TPA) 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
Claims
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 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


Care/Case Management


7 full time registered nurses with certifications in case
management
Disease Management


14 full time registered nurses with certifications in managed care
and care 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
Utilization Management


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
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-onone 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
Outcomes

Healthcare Effectiveness Data and Information Set (HEDIS®)

Clinical practice guidelines


Accessibility and availability


Primary care physician-driven guidelines from nationally
recognized sources
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
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
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
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
Mission Statement
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.
Thank You
Questions?