2. NetworX Integration Lee Paulus, Director Product Management, QNXT
Carolyn Keadle, Sr. Product Designer, NetworX

3. NetworX Suite® Overview
Integrated Provider Reimbursement Solutions
NetworX Pricer®
Pricing solution to automate even the most complex provider contracts
Eliminates errors and increases automation.
NetworX Modeler®
Model provider reimbursement contracts during negotiations or interim check points
Utilizes actual claim history from singe or multiple sources
NetworX Payment Bundling Administration™
Automate new bundle payments that involve multiple providers over period of time
Offers 30+ bundle definitions covering acute to chronic conditions
Licensing agreement with HCI3 Prometheus Payment™
Modeler
Pricer
Payment Bundling Administration
All three are core neutral and can integrate with multiple core systems

4. Achieving Balance Greater Automation Greater Cost Control
Boilerplate contracts
With higher auto- adjudication rates
But with higher medical costs
Greater Cost Control
Unique contracts for each provider
Maximizing medical cost savings
But with lower auto- adjudication rates
The NetworX Way
Enable sophisticated contracts
And increase automation
And lower financial risk
And win provider loyalty

5. NetworX Suite®: Solving Today’s Problems
Market Need
NetworX Solution
Accuracy of payments
Automatically and accurately calculate payment.
NetworX Pricer®, Modeler
Better communication
Eliminate costly research and improve relations by providing detailed info on how pricing was derived.
NetworX Pricer
ICD-10
How will the shift to ICD-10 impact reimbursement?
NetworX Modeler®, Pricer
Financial risk
Model proposals v. current contract. Identify outliers and lesser of impact. Reward physicians for efficient care
NetworX Modeler, NetworX PBA
New Methodologies
Administer new complex reimbursement methodologies, model current v. new
NetworX Pricer, NetworX Modeler, NetworX PBA
Contract Performance
Trend analysis of actual reimbursement v. expected reimbursement.
NetworX Modeler

6. NetworX Integrated Reimbursement Solutions
Rate Exhibit
Provider Contracts
Act on Key Opportunities
Contract Modeling
Negotiate & Finalize Rates
Auto-load, Configure Contracts
NetworX Modeler®
Contracting Phase
Operating Phase
QNXT Connectivity
Manage Medical & Admin Costs
Contract Analysis
Eligibility
Provider UM
Editing
Pricing (FFS & Bundled)
Adjudicate
NetworX Modeler®
NetworX Pricer®
Payment Bundling®
NetworX Functionality
NetworX Management Process
Ancillary Elements

7. Claims Processing with NetworX
QNXT™ Connectivity
Eligibility
Provider Match
Editing
Adjudicate
Contract Rate Sheet
Claim
EOB
NetworX Pricer®
and/or
Payment Bundling
Administration™

8. Pricing Accuracy and Accountability
NetworX Pricer®
NetworX Pricer®
Administers new payment methodologies
Eliminates errors in contract configuration/reimbursement
Automates accurate claims pricing utilizing over 350 calculations
Reusability streamlines configuration time and maintenance
Describes contract terms in easily understandable, readable format
Pricing details available for audits, customer service and EOPs reduce inquiries from providers

9. NetworX Building Blocks: Calculations
NetworX is delivered with a rich library of pre-built calculations (over 350 today)
Per Diems (40)
Case Rates (37)
Percent/
Discounts (16)
Stop Loss (54)
Unit/
Service (11)
Schedules (14)
DRG (27)
Minimum/ Maximums (15)
Allowed/
Reductions (20)
Others (APR-DRG, NY-APG)
Newly developed calculations are included in releases
Medicare/Medicaid using NetworX calculations and interface to third party groupers (Optum, 3M)
Designed to allow client development of new calculations
Revenue Codes 111 to 115 Set the Allowed Amount to $7,500 plus $900 per day.
Contract Term = Qualifier + Calculation

10. DRG Processing
Pre-processing to assign the DRG to claim (requires Optum/3M)
Use DRG that is on claim from source claim load.
Pricing
Utilize the DRG weight tables in NetworX. There are many calculations that use this data and some include outlier processing as well.
Group/Price using Optum based on PPS required.
Outliers can be applied based on DRG data, such as, mean LOS, high trim charges, etc.
Modeling opportunities
Use existing claim data to understand pricing for new markets (state schedules or commercial pricing).
Change weights, apply simulated dates, update charges for ‘lesser of’ processing/outliers, compare to CMS pricing

11. Medicare Pricing Integration with Optum Easy Group
Inpatient
Grouping (to assign DRG to claim)
CMS DRG Grouping Only
Grouping and Pricing
DRG Grouping and Pricing
POA/HAC options
CAH - Critical Access Hospital
IPF - Inpatient Psychiatric
IRF - Inpatient Rehab Facility
LTCH - Long Term Care Hospital
SNF - Skilled Nursing Facility
Outpatient
CMS APC – Ambulatory Payment Class
CMS ASC – Ambulatory Surgical Center
Critical Access Hospital
ESRD - End Stage Renal Disease
HHA - Home Health Agency
SNF - Skilled Nursing Facility
Physician Pricer
Medicare Physicien FeeSchedule
Lab. , DMEPOS, PEN
Ambulance
Multiple settings (office, facility, home)
Multiple provider types

12. Medicaid/Tricare Pricing Integration with Optum Easy Group
Inpatient
Grouping and Pricing
Georgia (Includes rate file)
Illinois
Michigan NY
AP and APR DRG
New Jersey
Ohio
Texas APR-DRG Eff 9/1/12
TRICARE
Washington State
Full listing can be found on Customer Exchange:
Outpatient
Michigan
NY EAPG grouping and pricing
TRICARE

13. Fee Schedule processing
Reusable schedules eliminates redundant data
Using the “Percent of NetworX Standard Fee Schedule” calculation provides great flexibility.
Multiple fee schedules can be included in single contract and applied based on qualifier.
Create “ad hoc” schedule carve outs
Fee Schedules include:
Procedure/modifier based schedule tables of fees, % of charge
RBRVS schedules
RVU
MDR/Fair Health
All or part of schedule can be referenced based on qualifier used in the calculation

14. Contract Modeling Process: NetworX Modeler® & Analytics
“What If” Scenarios
“What-if” Scenarios
View Modeling Results
Intuitive model building
Smart claim selection
Charge trending & date simulation
Customize code groups, schedules etc.
Initial Build & Model Run
Comparative Analysis
Deep Dive/Ad Hoc User Driven Analysis
Executive Summary/Dashboards
Iterative Analysis
Iterative Analysis
Analytics Pricing “
Discoveries “what-if” may require new model run in User Modeling
Analytics Reporting
Discoveries from Reporting may require new “what-if” Scenarios in Analytics Pricing
Initiate Models
Reporting & Analytics

15. NetworX Modeler® Process
Import Claims
From single or multiple sources 1
Build or Import Base Contracts
Import from NetworX Pricer® or other Modeler environments 2
Build or Import Contract Variations
Unlimited contract variations 3
Base
Contract
With
Rate variations
Per Diem
DRG w. carve-out
Medicare 4
Analyze the results
Supplied views
Ad hoc reporting
Exports

16. A Sample Contracting Model
Contract Scenario Results

17. A Sample Contracting Model

18. A Sample Contracting Model
Ad-hoc using modeled data
A Sample Contracting Model

19. Contract Modeling with Deeper Insight
NetworX Modeler®
Create unlimited scenarios for new methodologies
Use claim history from multiple sources
Compare current contract to proposals
Assess results against baselines e.g. Medicare
Simulate charge trending and date rages
Conduct case mix index analysis
Analyze Fee for Service vs. Bundled reimbursement *
Analyze impact of rate changes across the network, product line *
*2014

20. Payment Bundling
A group of providers agrees to accept a single prospective payment for all services in a well-defined unit of care
Targeted units of care are selected based upon
Ability to clearly define the unit of care operationally
Financial and quality impact
Involves multiple types of providers
Example: In addition to the inpatient stay for a hip replacement, a provider group includes the rehab facilities, primary care, ER, and other providers to deliver all care related to a hip replacement
Payment Bundling is being tested by CMS today
7 distinct ortho and cardio clinical conditions (38 DRGs)

21. NetworX Payment Bundling Administration™
Key Features
Pay provider group a single payment at the time of service delivery (that covers multiple providers for services over time)
Work with existing provider/payer processes, including authorizations, existing provider payment claims stream, and benefits processing
Support numerous and different definitions of payment bundles
Allow changes or customization to bundle design
Includes pre-configured bundles from national sources
Support different models of payment bundling (reference pricing, bundles with warranties, implement during, before, or after adjudication)
Designed to integrate into a payer’s core claims system
Can support multiple claims systems used by a payer

22. Implement new payment models
Payment Bundling™
NetworX Payment Bundling Administration™
All the benefits of NetworX Pricer® plus….
Automate pricing of multi-provider bundled contracts
Offers 30+ bundle definitions covering acute to chronic conditions
New definitions can be configured from scratch or modified from supplied data
Licensing agreement with HCI3 Prometheus Payment™
Fully integrated with Modeler (2014)

23. NetworX Payment Bundling Administration™
Business Logic
Payment Bundling Content
Claim
Core Administration System
Claim
Claim
PBA
Claim
Claim
Claim
Claim
Non Bundled
Claim
Claim
Bundled Claims
Single Bundled Payment
Provider Group
NetworX Payment Bundling Administration (PBA) Features:
Automates the payment of episodic care
Creates bundles from existing fee-for-service claims
Processes claim adjudication through claim repricing
Potentially integrates with any claims adjudication system
Contains powerful rules engine for automating bundle definitions
Handles pre-admission, post-discharge services and warranty care
Claim
Episodes are created and paid prospectively,
at the time of care delivery
Related Services

24. QNXT™/NetworX Integration Features
NetworX Pricer®/NetworX Integration Features to include:
Professional Claims….
NetworX Price for Professional Claims
Send Required information to NetworX Pricer
Process QNXT Benefit using NetworX Pricing Results
QNXT Edits fire in Claim for errors identified by NetworX Pricer
Error situations identified by NetworX to be displayed/available on the QNXT Claim so Processor can troubleshoot

25. QNXT™/NetworX Integration Features
NetworX Pricer®/QNXT Integration Features to include Cont.:
Institutional Claims….
NetworX Pricer for Intuitional Claims
Send Required information to NetworX Pricer
Process QNXT Benefit using NetworX Pricing Results
QNXT Edits fire in Claim for errors identified by NetworX Pricer
Error situations identified by NetworX to be displayed/available on the QNXT Claim so Processor can troubleshoot

26. QNXT™/NetworX Integration Features
NetworX Pricer®/QNXT Integration Features to include:
Estimates for Professional and Institutional Claims….
Allow copy/paste of Rate Sheet ID in QNXT Contract
Process Benefit for Estimate using NetworX Results
Error Situations identified by NetworX to be displayed/available on the estimate

27. QNXT™/NetworX Release Timeframes
‘To Infinity and beyond’
No more like - R6 –R9
Monitor Release Webinars and TriWiki

28. We would like to extend you an opportunity to provide candid feedback.
Workshop Survey
We would like to extend you an opportunity
to provide candid feedback.
During the workshop you should have received an notification for you to take an on-line survey.
If you could take a few minutes to complete at this time ,
we would greatly value your feedback. For your convenience, the survey will be available throughout the remainder of the conference should you not be able to complete immediately.

29. Thank You!