Presentation on theme: "InterACT 2007 Welcome to Highmark Primary Offices in Pittsburgh & Camp Hill along with satellite offices throughout the USA 18,500 Employees 4.6 Million."— Presentation transcript:
2 InterACT 2007Welcome to HighmarkPrimary Offices in Pittsburgh & Camp Hill along with satellite offices throughout the USA18,500 Employees4.6 Million Health Care Members28 Million Members Across all Products2008 Revenues: $12 BillionThis is a snapshot of Highmark today Highmark was created through the 1996 consolidation of Blue Cross of Western Pennsylvania and Pennsylvania Blue Shield. Today, we have 18,500 employees—the majority of which are employed here at our corporate headquarters and at our facilities in Camp Hill, Pennsylvania—outside Harrisburg.Our health care membership totals more than 4 million members. Highmark is a very large business and, in fact, we are the largest health insurer in Pennsylvania. Our revenues in 2006 were in excess of $11 billion.It's important to understand that Highmark is much more than an insurance company. Our product portfolio includes dental, vision and life insurance products offered through our subsidiaries. All told, through our health and subsidiary businesses, we cover more than 24 million people nationwide.
3 Strategic Initiative to Combat Health Care Fraud Three Phase ApproachEnhance query capabilities of existing claims history repositories.Purchase a provider scoring model which allows for automated detection of aberrant provider behavior.Purchase an automated claims scoring model which scores suspicious claims prior to payment.
4 Fraud Detection and Investigation Process Flow RuleBased DetectionDataToolsPeoplePhase IEvaluation /FinancialPredictivePrioritizationRecoveryModelingInvestigationRecovered orAverted CostsDataToolsPeopleDataToolsPeoplePhase IIProvider Scoring ModelDataToolsDataToolsPeoplePeopleReferralsProvider ClaimsPaymentDataToolsPeopleReviewPreventionDataToolsPeopleDataToolsPhase III -Predictive Modeling Claims Scoring ModelPeople
5 Implementing Pre-Payment Claims Scoring Technology Critical Success Factors:Efficient data transmission of claims (post adjudication but prior to physical payment).Building an effective evaluation team:Appropriate skill setsNew job rating/job classJob performance measurementsEstablish effective workflow processes between evaluation team and existing departmentsFraud casesAbuse casesPolicy changesSystem changesDefine and implement an effective value realization/ROI process
6 PROJECT ORGANIZATIONExecutive SponsorBusiness OwnerSteering CommitteeBusiness OwnerProgram ManagerProject ManagerClaims Processing VPEvaluation Team ManagerProgram ManagerInformation Services Group Project ManagerGovernance TeamAudit VPProgram ManagerEvaluation Team ManagerInformation Services Group TeamPre Payment TeamEvaluation TeamInformation Services Group Resources only needed until data extracts are in place
7 IMPLEMENATION TIMELINE Hourly Extract Implemented 09/09Model Construction and Data Gathering 09/09 – 03/26/10Go Live for Testing 03/29/10Implement IFM Pre-Payment Software 5/25/10Initial Steering Committee Meeting 6/9/10Year-end value realization and ROI statistics due to Steering Committee and Project Sponsor 12/31/10
9 Value Realization Term Definition Identified SavingsMonies identified from suspicious providers, contracting, system edits or medical policy issues identified by the FICO pre-payment software. Calculations for ROI are 12 months.Un-pursued savingsDollars identified by Pre-Pay but cost prohibited to pursue.Deny Button SavingsCalculated each time a team member denies claim payment.Previously Identified SavingsDollars identified by the software in which an active case is already addressing the issue.Savings referred to other plansDollars identified by Pre-pay but the case has been transferred to another plan (IBC, NEPA, etc.)Actual SavingsMonies received from refunds, restitutions, settlement agreements, claim offsets, and claim denials.Included in calculation of identified savings
10 Case Summary Unique Highmark Cases Opened 100 Highmark Cases Opened affecting multiple providers19Total Highmark cases opened259Cases related to un-pursued savings14Events related to previously identified cases2Cases referred to other plans5