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Perfect Clarity

FOCUS Behavioral Health. +. Perfect Clarity. Meeting Your Clinical and Information Technology Needs. 1. 2. 3. 4. 5. 6. H. 1. BEHAVIORAL HEALTH. Founded 1994

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Perfect Clarity

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  1. FOCUS Behavioral Health + Perfect Clarity Meeting Your Clinical and Information Technology Needs 1 2 3 4 5 6 H

  2. 1 BEHAVIORAL HEALTH • Founded 1994 • FOCUS is a Behavioral Review Organization located in St. Petersburg Florida which provides MD and clinician reviews for major insurers and MBHOs • We have Psychiatrists and non-MD clinicians on our panel of experienced reviewers • We conduct business through a proprietary clinical system our clients access through a secure web-based portal • FOCUS can modify its reviews to include client specific level of care guidelines, customized workflows and reporting 1 2 3 4 5 6 H

  3. 2 OVERVIEW • Founded 2004 • Perfect Clarity is another line of business for FOCUS BH • It specializes in consulting and development of customized process management systems for health care organizations • It provides or coordinates development and hosting of multi-platform relational database solutions • Perfect Clarity concurrently manages all IT solutions for FOCUS and is engaged in the automation of national MBHO firms. 1 2 3 4 5 6 H

  4. 3 FOCUS + PERFECT CLARITY Behavioral Reviews Care Management Client Automation 1 2 3 4 5 6 H

  5. 4 Agenda • FBH/PC - Who We Are • Data Analytics: Driving the Business • Organizational Considerations • Using Data to Manage Utilization • Client and Market Success Stories • Conclusion and Discussion 1 2 3 4 5 6 H

  6. 5 Data Analytic Themes Common MBHO & EAP Questions • How companies organize their data analytic functions • The types of data used to manage utilization • For what functions and analyses is this data used • Give examples of problems and solutions facing businesses today 1 2 3 4 5 6 H

  7. 6 Organizational Considerations 1. Key concern: centralized vs distributed data management 2. Most MBHOs have centralized data warehouses with input from multiple UM/Claims/Eligibility systems feeds • Advantages: standardized reporting used by multiple depts / ‘scrubbed data’ / tasks built around this data • Disadvantages: little flexibility for end-users / system downtime domino effect / complex QI processes 3. End-users still require own data ‘experts’ to access, set report parameters, QA and generate ad-hoc reports 1 2 3 4 5 6 H

  8. 7 Organizational Considerations 1. As a result, many companies use a combination of approaches-dedicated corporate data analytics departments and data analysts in field / regional offices: • 1 DA can support a large regional operation-usually reports to local executive, but can have dotted-line to corporate department • Corporate DA department size will vary - estimate 5-10 FTEs will report to CIO / Chief Clinical Officer for a large organization 1 2 3 4 5 6 H

  9. 8 Organizational Considerations 1. Common practice - develop local ‘one-off’ DBs to support UM process • Allows more timely ad-hoc analysis of acute care utilization data • Tracking of local program initiatives - how many IP diversions from admissions requests • Data doesn’t match centralized UM data, but should be close enough to be useful • IP days measured in month of admit or discharge 1 2 3 4 5 6 H

  10. 9 Data Used to Manage Utilization Trend 1. Primary Data Streams • Member Tape Loads - Eligibility Accuracy • Encounter Data • Claims Adjudication Verify billed vs. paid vs. acutal 1 2 3 4 5 6 H

  11. 10 Data Used in Analyzing Utilization Trend 1. Ancillary Data Streams • Medical/Surgical Encounter Data • Workers Compensation • Disability Data • Pharmaceutical Claims 1 2 3 4 5 6 H

  12. 11 Data Used to Manage Utilization Trend Providers and Facility Networks • Facility Scorecard • Provider profiling (using auth or claims data) • Frequency of accommodations for OON facs Key claims based metrics allows comparisons between facilities Facility ALOS / discharge appts / comparative data Attending MDs utilization - no. of cases / ALOS • Frequency and outcomes of clinical appeals • Compliance with precertification and LOC protocols 1 2 3 4 5 6 H

  13. 12 Data Used to Manage Utilization Trend Care Management • Staffing ratios vs. actual FTEs • Case load analysis • Care Managers and Medical Director relationship - IRR • ALOS Membership • Review member mix - MC Dual Eligibles and MC Advantage • HP expansion into new geographic areas or new lines 1 2 3 4 5 6 H

  14. 13 Data Used to Manage Utilization Trend Employee Assistance Program 1. Penetration rate % Membership using EAP. Definition is important. 2. Members referred to non-benefit resources 3. Members referred to MHSA benefits 4. Gatekeeper model % of EAP referrals using MHSA 5. Website page viewing analysis F PC R H

  15. 14 Client/Market Successes FOCUS Client A Presenting Problem: • Decentralized data model • Minimal use of relational data architecture • Primitive organization of Word & Excel documents • No web portal for remote offices • Poorly documented policies & procedures • Difficulties with QA • Inconsistent & inaccurate use of industry terminology 1 2 3 4 5 6 H

  16. 15 Client/Market Successes FOCUS Client A Solution • Consultative review of all business needs • Development of software prototype • Cycle of presentation, modification and re-presentation until acquisition of company approval • Development of Customized Data Management System • Presentation, final edits and signoff by management • Implementation, training and ongoing improvement 1 2 3 4 5 6 H

  17. 16 Client/Market Successes FOCUS Client A Resolution • Centralized data repository provides enhanced security, HIPAA compliance & automated quality controls • Auditing and QA greatly enhanced • All offices participate in real-time data environment • Remote/home based employee model now feasible • Accurate and up-to-the minute reporting • Data mining provide analysts multiple perspectives 1 2 3 4 5 6 H

  18. 17 Client/Market Successes Wellcare Rationale Presenting Problem: • Utilizing InterQual™ criteria with a combination of Medicare, Medicaid and commercial plans, rationale verbiage submitted by Physician Advisors was often out of compliance due to the multitude of combinations and complex plan requirements. 1 2 3 4 5 6 H

  19. 18 Client/Market Successes Wellcare Rationale Generator Demonstration Solution & Resolution • Organization of rationale components into 3 segments: • Preamble • Application of InterQual™ Criteria • Suffix • System now auto-generates compliant rationales and allows Physician Advisor to customize finalized documentation 1 2 3 4 5 6 H

  20. FOCUS Behavioral Health + Perfect Clarity Meeting Your Clinical and Information Technology Needs Thank You 1 2 3 4 5 6 H

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