Presentation is loading. Please wait.

Presentation is loading. Please wait.

Provider Workshop North Carolina Health Insurance Institute

Similar presentations


Presentation on theme: "Provider Workshop North Carolina Health Insurance Institute"— Presentation transcript:

1 Provider Workshop North Carolina Health Insurance Institute
October 26-27, 2017

2 About MedCost

3

4 A Who We Are INTEGRATED Founded in 1983, MedCost is a benefits solutions company based in Winston Salem, NC, serving employers through NC, SC and VA through: Third party administration for self-funded businesses ranging in size from 50 – 25,000 employees Care Management programs cited as best in class by national consulting firms Proprietary network of 75,000+ providers We remain committed to our contracted providers and welcome the opportunity to collaborate on innovative industry initiatives, while keeping the greater concept of value in mind for our clients and your patients. MedCost has 30+ years experience developing innovative care management programs and managing an extensive and stable provider network 1983 MedCost formed and PPO Network and Utilization Review programs developed 1996 MedCost acquired by Carolinas HealthCare System and North Carolina Baptist Hospital 1998 MedCost Benefit Services formed as TPA to gain more control over distribution of products and services to better compete with large national carriers TRANSITION: After 30+ years these are some of the companies who have chosen to work with us.

5 The Evolution and Growth of MedCost Journey to Integrated Benefits Solutions
Providing TPAs and Insurance carriers with a PPO Network in NC and Medical Management Services 1983 1998 2006 2011 Started TPA to offer employers full-service integrated programs MedCost ownership change - CHS and WFBH Acquisition of Health Care Savings (PPO) network Launched nurse coaching program for at-risk population Expanded product offerings to include pricing transparency and online health and wellness Expanded product options to include behavioral health, reference pricing and benefit administration solutions 1990 2003 2014 Expansion of PPO Network to South Carolina Launched Maternity Management Program Acquisition of Piedmont Administrators (TPA) Expanded services to include COBRA administration Invested in integrated advanced analytics Deployed telehealth product offering 2009 Acquisition of Medical Claims Management (TPA) 2017 Acquisition of Virginia Health Network (PPO) MedCost Today 34 years of experience providing solutions to employers Regional presence in NC, SC and VA 260 employees; headquartered in Winston-Salem, NC TPA serving 190,000 members Network serving 350,000 members Strong provider network in the Carolinas and Virginia with over 75,000 participating providers Administered $1.5 billion dollars in health care in 2016, balancing cost and care with integrated solutions

6 Population We Serve Health Care Providers Employers Consumers
Programs and services that provide affordable health benefit options Improve health of employee population Alternative to insurance companies Comprehensive benefit plans Health and wellness programs Higher level of flexibility, customization, service and affordability Employer-specific reporting True partnership Improving health care through strong consumer engagement programs Consumer-friendly programs offering broad access and choice Care management programs to advocate for patients and their families Transparency tools to empower consumers to make informed health care decisions Exceptional member services An alternative that allows providers to diversify their payer mix which promotes competition in the marketplace Collaborative relationships in achieving affordable health care Robust data sharing to identify cost trends Managing benefits for over 40 hospitals and their employees Strategic partnership on behalf of the community and our membership

7 Our Clients Headquarters

8 Regional & National Network Solutions
Primary Network Ancillary Network Multi-State North and South Carolina (MedCost Network) Virginia (Virginia Health Network) Progressive Contracting Strategies Comprehensive Access Pricing Transparency URAC-Accredited in Provider Credentialing Innovative Network Solutions Strategic partnership with national network for primary coverage for members residing in other states or traveling MedCost Network Largest independent PPO network in the Carolinas Comprised of more than 11,000 primary care physicians, over 27,000 specialists and more than 1,300 hospitals/facilities/ ancillary providers MedCost Ultra partnered with Virginia Health Network in VA. Ancillary (leased) Network Access to national networks for primary PPO and travel LSP NOTES: MBS Direct & Ultra: contracting strategies not available to TPAs leasing the MedCost PPO network. Competitive Markets: Charlotte, Asheville, Hickory, Winston-Salem, Greenville, NC

9 Benefit Solutions Administrative Services
Consumer Driven Health Plans Claims Administration Ancillary Services Medical Prescription Stop Loss Dental Vision Flex Spending Accounts COBRA Compliance Underwriting HIPAA Disability Benefit Design Health Reimbursement Accounts Health Savings Accounts MedCost comes with 15+ years experience, a flexible, open architecture plan designs, and comprehensive administrative services that exceed industry expectations. We can deliver: Expertise and guidance on benefits and funding options that fit an employer’s business needs and goals Administration of an employer’s plan based on their specifications Seamless interface with a client’s preferred vendors and partners TRANSITION: We understand the special needs of self-funded clients and offer ancillary services to support those requirements – like customized stop-loss protection and legal expertise to help navigate health care compliance requirements. LSP NOTES: Seamless interface with a client’s preferred vendors and partners for ancillary products Evaluating an enrollment platform that would streamline data exchange.

10 MedCost Core Competencies Integrated Health Solutions Experts
Core Administration & Claims Adjudication Customer Service INTEGRATED SOLUTIONS Data Analytics Compliance We believe our value proposition is a fully integrated benefits solution. Network claims will go to a single location Health management team will have access to eligibility, benefits, and claim information. Clinical Care Management Network Management

11 A Hybrid that Makes Us Different
The sophistication and integration of a national brand combined with the flexibility, pricing and service of a local business Solutions Management Flexible Network Customer-Focused Care Management TIP… Use this slide to wrap-up and reconnect to the audience benefits sited at the beginning of the presentation. LSP NOTES: We are large enough to offer all the bells and whistles of a carrier but small enough that we do not lose sight of what’s important to you our customer…..flexibility, customization, reporting, and customer service. Customized Pharmacy Benefit Management Health & Wellness Integrated

12 Service Excellence

13 Service Excellence Customer Service Results
2015 2016 Call Center Calls Resolved on First Contact 95% 97% % of Calls Answered Within 30 Sec 75% 73% Average Speed of Answer 26 sec 29 sec Caller Satisfaction Real-Time Audit of Calls 96% Web Chat 11 sec 16 sec % of Chats Answered Within 10 Sec 87% 99% Same and better than industry benchmarks/matrix. 97% of caller when they hang up their issue has been resolved. The remaining 3% are resolved within 48hours….claim correction or review, eligibility, anything that requires referral outside that business unit. Call satisfaction is measured by… random selected 2% of callers is asked if they would like to take a 5 question survey which is ed. Any negative responds (below acceptable level) are followed up telephonically or via to find out why they rate the experience that way and what could be done differently. Accuracy of call audits - Two people dedicated to auditing calls live and record – to identify training needs and trends about certain issues in all business units – ID card example. LSP NOTES: 93% of caller when they hang up their issue has been resolved. The remaining 7% are resolved within 48 hours….claim correction or review, eligibility, anything that requires referral outside that business unit.

14 Service Excellence Claims Operations Results
2015 2016 Average Claim Turnaround 4.5 days 5.3 days Auto Adjudication 59.2% 60.6% Claim Procedural Accuracy 99.8% Claim Financial Accuracy 99.5% 99.7% % of Electronic Claims 99% Average claim turnaround is 5 business days – the goal is 10 days. Low auto adjudication numbers (industry is somewhere around 75-80) is due to high standards for accuracy affords by a very careful implementation process. Claim procedural and financial accuracy is based on combination of claim audits, customer service referral, new group audits and check run audits and adjustment audits (re-work transactions) High percent of electronic claims due to technology and recruitment and resources to build out electronics to where they are today. LSP NOTES: Average claim turnaround is 5.3 business days – the goal is 10 days.

15 The Changing Landscape of Health Care – Trends
Employer offers self-funded plan to 26

16 Reference-Based Pricing Limited/High Performance Networks
Industry Landscape Current Environment – All Players Concerned about the Future Employer Concerns Member Concerns Focus on Affordability Changing landscape with ACA Uncertainty of Future Company Viability Want a Voice in their Care Want Choice in Benefits/Providers Want Affordability Emerging Models PCMH Value-Based Pricing Reference-Based Pricing Limited/High Performance Networks Provider Concerns* Payer Concerns Need for Quality Focus Need to Deliver Affordability Need to Deliver Transparency Shrinking Reimbursement Levels Access to Information Need for Quality Focus Technology Challenges ICD-10 * Source: BeckersHospitalReview.com

17 Industry Landscape Triple Aim Commitment
Population Health TRIPLE AIM COMMITMENT Experience of Care Cost Per Capita

18 MedCost & MedCost Benefit Services
Industry Landscape Current Environment – All Players Concerned About the Future Price sensitive market focused on affordability Health care reform and provider consolidation continue to drive increased costs Innovative solutions needed for old and new problems Growth in consumer driven health plans (HDHP) to drive individual responsibility Health Care Reform is a catalyst for change Private Exchange: 33% of employers would consider offering ACA concerns expand interest in self-funding to smaller employers Government programs seeking more affordable options Movement of “pay for volume” to “pay for value” Employers expect different and effective solutions Physicians/hospitals moving to valued based models (ACOs/CINs) Medicare/Medicaid costs driving innovative payment structure Success/ Effectiveness to be determined Increasing focus and popularity of self-funding Effective management of health plan costs Timely response and issue resolution Commitment to reinvesting in technology Solutions management Experienced partner TIP: Use this slide to discuss and probe for what your audience is interested in, i.e., “When thinking about providing this important benefit to your employees, in today’s environment, what are your concerns?” Very Price Sensitive Market -- Primary focus is affordability Sluggish economy pressures health cost trend Health care reform will increase costs in 2014 Innovative solutions needed for old and new problems Individual consumers making benefit purchase decisions Health Care Reform is a catalyst for change Private Exchange: 56% of employers would consider offering PPACA concerns spark interest in Self-Funding More larger employers and smaller employers Government programs seeking more affordable options Movement of “pay for volume” to “pay for value” Employers expect different and effective solutions Administrative, Clinical, Wellness and Payment Physicians/hospitals moving to valued based models (ACOs) Medicare/Medicaid costs driving innovative payment structure TRANSITION: More and more employers are venturing into self-funded benefits plans. For groups new to these funding arrangements, the benefits of teaming with an experience partner can’t be overstated. MedCost & MedCost Benefit Services

19 Value Based Reimbursement Methodologies
Focuses on reducing inappropriate care and identifying and rewarding best-performing providers Medical Home Models Incentives for primary care to coordinate care and meet specific quality metrics. Primary care physicians are paid an additional PMPM for their care coordination efforts in addition to fee for service (PPO model) Pay for Performance Provider payments based on meeting defined quality metrics. Some tiered models being defined as Pay for Performance are actually based on moving providers with the best pricing (discount) into a higher reimbursement tier Bundled Payments Identify specific episodes of care and determine reimbursement for the episode that bundles payment for all service providers involved TIP… Use this slide to provide examples of how MedCost is constantly monitoring industry trends and innovations and then adopting new methodologies to reduce inappropriate care reward high performing providers.

20 Network Pricing Transparency
Member Price Comparison Tool Allows members to access episodic costs for certain medical procedures, based on the MedCost PPO provider allowable 75 different procedures Nationally recognized quality indicators and members’ feedback about provider experiences Within our network we have invested in technology to promote true pricing transparency with… HealtheReports Member Price Comparison Tool Allows members to access episodic costs for certain medical procedures, based on MedCost Network provider allowable Currently 64 different procedures View nationally recognized quality indicators and feedback from other members on experiences with a particular provider TRANSTION to Managing the Health of Your Population… We’ve talked about bare-bones of an employer’s health care plan – benefit design, admin services and network. But we don’t stop there.

21 Care Management

22 The Mission of Care Management
Manage member needs while promoting efficient use of health care resources with targeted assessment • education • intervention TIP: Use this slide to introduce MedCost’s Care Management programs and the deep and wide bench of experience and expertise used to help individuals living with illness and manage costs in the Acute, Chronic and Catastrophic health care settings. Under the “Care Management” umbrella we offer Utilization Management programs (aimed at Acute population), Nurse Coach and Disease Management programs (aimed Chronic population), and Catastrophic Case Management programs. Average Tenure 22 years nursing experience 22 years management team Staff Expertise 22 nurses on staff including 8 CCMs Clinical Leadership Seasoned Medical Director and panel of 70 physician consultants

23 Utilization Management Process Focus
Balance the needs of the patient with an efficient process for the provider to achieve top quality outcomes PATIENT PROVIDER Eligibility Verification Service Review Proactive Discharge Planning Timely Notification Referral to MedCost Care Management Support Programs Web and Telephonic Certification Available Immediate Referral Assignment Eligibility Verification Timely Notification Peer-to-Peer availability per Providers schedule TIP: Use this slide to introduce MedCost’s Care Management programs and the deep and wide bench of experience and expertise used to help individuals living with illness and manage costs in the Acute, Chronic and Catastrophic health care settings. Under the “Care Management” umbrella we offer Utilization Management programs (aimed at Acute population), Nurse Coach and Disease Management programs (aimed Chronic population), and Catastrophic Case Management programs.

24 Utilization Management Program Results
2015 2016 National Avg1 Inpatient Review Days per 1000 lives 145 139 168 Admissions per 1000 36 33 Readmission rate within 30 days 4.5% 3.8% 7.9% Average certified days 4.0 4.2 4.7 Requested days not certified2 13.2% 12.9% Outpatient Review ROI 5.7:1 5.4:1 Procedures not approved 4% 4.3% MRI3 4.7% 5.3% CT Scan4 3.9% MedCost’s discharge planning and utilization review received Best Practice designation from a national consulting firm indicating that our programs validating the strength of our programs. 1 MCG Guidelines 21st Edition 2 Cost avoidance of approx. $4,800 per day avoided 3 Cost avoidance of approx. $2,907 per procedure avoided 4 Cost avoidance of approx. $4,112 per procedure avoided

25 2016 Care Management Outcomes
CASE MANAGEMENT PERSONAL CARE MANAGEMENT SMARTSTARTS TELADOC Participation Rate 95% ROI 5:1 Patient Satisfaction 100% Participants with High Risk 65% ROI 33:1 Patient Satisfaction 100% Participants with Positive Health Status Change 90% Reduction in A1C 90% Reduction in Blood Pressure 48% Reduction in Avoidable ED Visits 4 ROI Range 3:1 to 6:1

26 Explaining Pharmacy Trend
Price Inflation Big driver! Manufacturer price hikes Estimated 16-17% increase in brand-name and specialty drug costs per year Specialty Medications Treatment of rare, previously untreatable diseases Influx of new drugs to market Accounts for approximately 35-45% of pharmacy spend, expected to increase to 50% by 20181 Increased Utilization Healthcare knowledge more readily available Emphasis on health & wellness Generics control increasing trend by promoting competition Notable in 2016: Crestor, Zetia, Benicar Problems? biosimilars, patent extenders Estimated 80 Rx TV commercials per hour, 24 hours a day2 28% of patients ask their doctor about a Rx seen advertised & 12% say their doctor prescribed the advertised medication3 Patent Expirations Advertising American Journal of Managed Care, “The Growing Costs of Specialty Pharmacy—Is This Sustainable?”, Feb 8, 2013. NPR.org, “Selling Sickness: How Drug Ads Changed Health Care”. Kaiser Family Foundation, “Prescription Drug Costs Remain Atop the Public’s National Health Care Agenda, Well Ahead of Affordable Care Act Revisions and Repeal”,

27 Care Management Program Integrated Care Team with the Provider
MedCost Care Managers connect with the entire clinical care team to meet the patient goals through support of the providers treatment plan Educates patient to close clinical gaps in care Facilitates Home Health Care, Durable Medical Equipment, etc. Notifies PCP of ER utilization, clinical gaps in care, current and predictive risk factors Provides social and financial support and referrals Coordinates high cost specialty medications TIP: Use this slide to introduce MedCost’s Care Management programs and the deep and wide bench of experience and expertise used to help individuals living with illness and manage costs in the Acute, Chronic and Catastrophic health care settings. Under the “Care Management” umbrella we offer Utilization Management programs (aimed at Acute population), Nurse Coach and Disease Management programs (aimed Chronic population), and Catastrophic Case Management programs. MedCost Care Manager

28 Managing the Health of Your Population
Health & Wellness Acute Health Promotion Health Risk Assessment Biometric Health Screenings Health Coaching Gaps in Preventive Care Member & Provider Outreach Behavioral Health Substance Abuse Depression Anxiety Chronic Pain Management Health and Wellness Toolkit Personal Health Suite Online Resource Lifestyle/Behavioral Health Programs Personal Health Record Health Tools & Trackers Utilization Management Inpatient & Outpatient Care Review All inpatient admissions MRI, CT, PET Behavioral Health Intermediate Levels of Care Emergency Department Utilization Outreach Pre/Post-Discharge Planning Telehealth At-Risk/Chronic TIP: If necessary this single slide could be used to explain MedCost’s 1)Health and Wellness and 2) Care Management programs that addresses the entire continuum of care to manage medical and Rx claims cost. From healthy and staying healthy to assisting those living with illness, we can design a custom solutions that leverages the greatest cost control opportunities. Nurse Coaching and Chronic Disease Management Personal Care Management Nurse Coaching Transitional Care Cellular-Enabled Diabetes Management Solution Maternity Management (SmartStarts) Chronic Disease Education Complex Complex Case Management Transplants Dialysis Oncology Behavioral Health Rehab High Risk Maternity Chronic Complex

29 MedCost Administration

30 MedCost Network Request for verification of benefits should be directed to the claim administrator as indicated on the member’s ID card. MedCost does not maintain member level eligibility. Plan design will vary by each individual employer group. Ensure you check benefits so that you may collect appropriate co-payment or co-insurance amounts at the time of service. Provider may collect co-insurance amounts based on actual charge.

31 MedCost Network Online Tools – Non-Secure Portal
No registration/password required and have access to the following: Locate a Provider Provider Manual (part of your contract) Update Demographics Credentialing Information Provider Education Payers with Online Claim Status News – register for eCommunications

32 MedCost Network Online Tools – Secure Portal
Under MedCost Network - Web Applications Services, you can select from the following to obtain useful information: Claims Repricing Inquiry Reference Guides Physician Claim Activity Report Facility Claim Activity Report Fee Allowables

33 MedCost Benefit Services - TPA Online Tools – Secure Portal
Under MedCost Benefit Services, you can select from the following to obtain useful information: View claim status (search by claim number, patient name or date range) View member eligibility Display benefit plan details Submit NPI numbers Contact customer service

34 Thank You For Participating!
Contact Information Customer Service Contact Center Monday - Friday, 8:30 a.m. to 5:00 p.m. Visit our website at Thank You For Participating!

35 Questions?


Download ppt "Provider Workshop North Carolina Health Insurance Institute"

Similar presentations


Ads by Google