2. AQATICS

3. AQATICS TEAM Sharon Cipicchio Bill Pieper Norm Littlefair Theresa Liakopoulos Brad Rybicki Donna Dewar

4. I. WHAT IS AQATICS? Allied Quality Awareness Team Improving Customer Service

5. II.WHAT ARE THE OBJECTIVES OF THE PROGRAM? Provide better service to participants by handling correspondence more accurately, consistently, and timely. Develop, clarify or modify departmental procedures through feedback from reviews.

6. Eliminate procedural inconsistencies between analysts and between departments. Determine if any quality deficiencies exist among staff and develop assistance for them through retraining. II. WHAT ARE THE OBJECTIVES OF THE PROGRAM? (cont.)

7. III. WHAT CAN BE GAINED BY AN EFFECTIVE AQATICS PROGRAM?  Less hardship on the members because their inquiries are processed accurately and timely.  A decrease in phone calls to Toll-Free as well as the number of TKPR referrals sent to the Research Department.  A decrease in inventory backlogs.  Increased satisfaction amongst local unions, providers, and PPO networks.

8. IV. WHO WILL BE REVIEWED?  Analysts doing non-committee batch work (RSA, RR4, RPB)  Analysts doing committee appeal work (RFC, RAC, RBT)  Teamleaders

9. V. HOW WILL REVIEWS BE CONDUCTED?  Random and retrospective from weekly TKPR production reports  Batch Work  Done by Norm and Theresa on alternating basis  Based on random selection, items to be pulled by Workflow Clerk and replaced with “out card” for easy identification  A special bin for re-files will be set up for analysts and reviewers to return work after review is completed  To assist process, analysts must file all their closed-out work in the proper batch by the end of the week

10. V. HOW WILL REVIEWS BE CONDUCTED? (cont.)  Committee Appeal Work  Done as they are currently oRFC write-ups and letters by Norm oRAC and RBT write-ups and letters by Theresa and Bill  Since all Committee write-ups and letters are currently reviewed upfront, any errors identified will be recorded and kept in a holding file. If at a later time, the random selection calls up one of these files, the error will be assessed at that time.

11. VI.WHAT IS ACTUALLY BEING REVIEWED?  Batch Work Analysts  100% of one day’s work per month based on the daily average attained by the analyst the previous quarter.  The review will be conducted on the research of the file and the resulting final action. This would include letters, payment referrals, and the content of any fact sheets, such as medical exclusions or 10% penalties presented to supervisors or manager for review. Technical errors on fact sheets will be informational only.

12. VI. WHAT IS ACTUALLY BEING REVIEWED? (cont.)  Batch Work Analysts (continued)  When analysts work on multiple categories of work during a review quarter, at least 50% of the review will be in the analyst’s specific assigned category of work, if available.

13. VI. WHAT IS ACTUALLY BEING REVIEWED? (cont.)  Appeals Committee and Staff Final Review Committee Analysts  100% of their write-ups and letters will be reviewed as they are now.  Errors will be recorded and kept in a folder for potential future random selection and assessment.

14. VI. WHAT IS ACTUALLY BEING REVIEWED? (cont.)  Appeals Committee and Staff Final Review Committee Analysts (cont.)  Committee write-ups are reviewed for content and presentation of facts. Technical errors on write-ups are informational only.  When analysts work on multiple categories of work during a review quarter, at least 50% of the review will be in the analyst’s specific assigned category of work available.

15. VI. WHAT IS ACTUALLY BEING REVIEWED? (cont.)  Trustee Appellate Review Committee Analysts  100% review of work based on exposure, and low number of completed files due to the nature of the work performed.

16. VI. WHAT IS ACTUALLY BEING REVIEWED? (cont.)  Teamleaders  Sample size will equal the group incentive average attained during the previous quarter.  A random selection of all work categories will be selected.  Letters for Manager or Director signature will be reviewed as they are presently and errors will be recorded and kept in a holding file. If at a later time, the random selection calls up the file, the error will be assessed at that time.

17.  Two types of errors – weighted separately:  Significant  Technical  Error Index (separate listing attached):separate  Correspondence Procedural Handling Errors  Final Action Errors  These are broad categories at this point. The AQATICS Team will continue to look at refining the listings as we begin the program and get feedback from the reviews. VII. WHAT CONSTITUTES AN ERROR?

18. VII. WHAT CONSTITUTES AN ERROR? (cont.)  Acceptable Error Percentages  To be developed as we are able to get review data over the first several quarters of the program.

19. VIII.HOW WILL YOUR PROGRESS BE REPORTED TO YOU?  Results of each review will be reported to you.  If an error needs to be corrected, since you have already received credit for this file, no additional credit will be given.

20. VIII. HOW WILL YOUR PROGRESS BE REPORTED TO YOU? (cont.)  Two Step Appeal Process available:  First appeal to reviewer  Second appeal to Review Committee consisting of the other two management team reviewers, not part of the original review  If Review Committee is deadlocked, final ruling made by Director

21. VIII. HOW WILL YOUR PROGRESS BE REPORTED TO YOU? (cont.)  Quality Profile Distributed Each Quarter  Will incorporate summary of all reviews from the quarter along with any additional performance feedback such as file aging or referral errors from other departments

22. IX. WHEN WILL THE PROGRAM BEGIN?  The program will begin the first full week after the AQATICS informational meeting.  For the first quarter, to get our feet wet, we will review one day’s average of work for the quarter (not for each month) for each analyst not subject to 100% review.

23. X. IMPORTANT THINGS TO REMEMBER  The program is not designed to be punitive and would only become so if an individual distinguishes himself or herself with a problem.  The first and second quarters will be strictly informational and a way to gather information, develop, and refine the program.

24. X. IMPORTANT THINGS TO REMEMBER (cont.)  Once the program is finalized and we can determine what are acceptable error percentages, analysts will begin in the non- disciplinary category. The results of their quarterly review could move them into different categories of review such as retraining or if necessary, a disciplinary category.

25. X. IMPORTANT THINGS TO REMEMBER (cont.)  The AQATICS Team will continue to meet regularly to discuss error categories, procedures, retraining and ideas which can improve the program.

26. X. IMPORTANT THINGS TO REMEMBER (cont.)  And most importantly… …there can be no AQATICS without “U” !