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North Jersey IIA Software Expo Data Mining-driven Eligibility, Dependent Eligibility and Claims Auditing May 17, 2007

North Jersey IIA Software Expo Data Mining-driven Eligibility, Dependent Eligibility and Claims Auditing May 17, 2007. Contents. Introductions and Overview The Business Case Audit Survey Responses and Case Studies Web-based Technology Next Steps. Introductions and Overview.

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North Jersey IIA Software Expo Data Mining-driven Eligibility, Dependent Eligibility and Claims Auditing May 17, 2007

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  1. North Jersey IIA Software Expo Data Mining-driven Eligibility, Dependent Eligibility and Claims Auditing May 17, 2007

  2. Contents • Introductions and Overview • The Business Case • Audit Survey Responses and Case Studies • Web-based Technology • Next Steps

  3. Introductions and Overview Web: Eligibility Auditing Case Management Audit Dependent Audit Clinical and Disease Management Audit DIFFERENTIATORS Medical Claims • Comprehensive • ROI-driven • Independent • 100% Data • Data Mining • Root Cause • Passion Rx Claims Eligibility 2007 2006 2005 2004 2003 2002 2001

  4. Introductions and Overview - Technology Model SPDs, ASO Contracts and Reports Census Rx Enrollment COBRA Medical Cleanse • Business/Audit Needs: • Eligibility • Dependent Eligibility • Subrogation • Discounts • Financial • Limits • Exclusions • Rx rebates • Other Load Member Data Warehouse Query Reports Suspects

  5. The Business Case * Excludes recoveries from payor ** Includes a 2% reduction in spend plus a 10% trend *** Includes a 3% reduction in spend plus a 10% trend

  6. Survey Responses and Case Studies – Why Perform an Audit? RESPONSE EXAMPLE • #1 – Recapture overpayments ESRD Medicare • #2 – Contain future costs Point-in-time Eligibility • #3 – Identify root cause improvements Subrogation • #4 – Contribute to vendor negotiations • #5 – Perform due diligence

  7. Survey Responses and Case Studies – Which Medical Areas Should Be Audited? RESPONSE EXAMPLE • #1 – Discounts (consistent across all responses) N/W Discounts & Access Fees • #2 – Limits and exclusions Gastric Bypass • #3 – Stop loss Plan Year Straddle • #4 – Member liability • # 5- Employee eligibility Low Hours • #9 – Subrogation and coordination of benefits

  8. Survey Responses and Case Studies – Which Rx Areas Should Be Audited? RESPONSE EXAMPLE • #1 – Limits and exclusions Biotech • #2 – Discounts AWP – Marketing Vs. Contract • #3 – Rebates Contract – In/Out • #4 – Member Liability Systemic Co-payment • #5 – Stop Loss

  9. Survey Responses and Case Studies – What Are The Top Attributes? • RESPONSE FACT • #1 – Data Warehousing Technology Data Mining/web • #2 – Specific Payor Experience National Payors/PBMS • #3 – Cost • #4 – Performance Guarantees 100% ROI + • #5 – Return On Investment Several Hundred %

  10. Web-Based Technology: Eligibility Dashboard Example Plan statistics as well as query summaries are provided in the Dashboard Summary Users can refine the standard query selection criteria by changing the search criteria The query result can be easily downloaded to Excel for further analysis

  11. Web-Based Technology: Beyond Termination Example In this example we looked for claims greater than $200 and term dates after Sept. 1, 2005

  12. Web-Based Technology: Low Premium Example This query identifies tier mismatch suspects

  13. Web-Based Technology: Dependent Confirmation Web Page Employees are presented their dependents and are asked to confirm eligibility Alternatively, employees can be prompted with “fill-in-the blank” questions regarding their dependents Employees can be asked questions about spousal employment and their respective benefits insurance or questions regarding their college age child to ensure eligibility

  14. Web-Based Technology: Dependent Audit Dashboard - 24/7 ROI Member activity metrics are available 24/7 via the web The actual savings based upon claim spend is available 24/7 via the web. Savings Also be computed on a per-capita basis The actual savings by relationship type is available 24/7 via the web

  15. Web-Based Technology: Departmental Healthcare Spending Our system also helps users understand member spend by organizational unit

  16. Next Steps • Stop by our booth • Ask us about potential leakage in your plan • Contact Howie Gerver at 201.891.8010 or, Howie@HRBestPractices.com; or Ed McDermott at 201.818.9196 or Emcdermott@HealthCostSolutions.biz • Thank you for your time and interest!

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