perfect clarity meeting your clinical and information technology needs focus behavioral health +...
TRANSCRIPT
Perfect Perfect ClarityClarity
Meeting Your Clinical and Meeting Your Clinical and Information Technology NeedsInformation Technology Needs
FOCUS Behavioral FOCUS Behavioral HealthHealth
++
1 2 3 H4 5 6
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
11
1 2 3 H4 5 6
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
22
1 2 3 H4 5 6
BehavioraBehaviorall
ReviewsReviews
ClientClientAutomatioAutomatio
nn
CareCareManagemeManageme
ntnt
FOCUS + PERFECT CLARITYFOCUS + PERFECT CLARITY
33
1 2 3 H4 5 6
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
44
1 2 3 H4 5 6
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
55
1 2 3 H4 5 6
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
66
1 2 3 H4 5 6
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
77
1 2 3 H4 5 6
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
88
1 2 3 H4 5 6
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
1 2 3 H4 5 6
99
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
1010
1 2 3 H4 5 6
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
1111
1 2 3 H4 5 6
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
1212
1 2 3 H4 5 6
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
1313
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
1414
1 2 3 H4 5 6
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
1515
1 2 3 H4 5 6
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
1616
1 2 3 H4 5 6
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.
1717
1 2 3 H4 5 6
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
1818
DemonstrationDemonstration
1 2 3 H4 5 6