PCIP-WA ADMINISTRATOR S REPORT September 2011 An Executive Summary of Administrator s Monthly Operations Report and HHS Report

Transcription

1 PCIP-WA ADMINISTRATOR S REPORT September 011 An Executive Summary of Administrator s Monthly Operations Report and HHS Report INCEPTION-TO-DATE ENROLLMENT SUMMARY Total Enrolled/Approved as of 09/30/11*: 650 *Coverage may not be effective until a subsequent month Number/percentage sponsored by Third Party: 65 (41%) Percentage of sponsored enrollees from EHIP: 98% Percentage of sponsored enrollees from other: % Enrolled/Approved ITD: 781 Newborns Enrolled ITD: 0 Terminations ITD: 14 Plan Selection: $,500 deductible plan 55% $500 deductible plan 45% Top five pre-existing conditions: 1. AIDS. Cancer 3. Pregnancy 4. Diabetes 5. Crohn s Disease Age & Demographics: Average age: 4 Gender: Female 43%, Male 57% Top five counties of residence: King, Pierce, Snohomish, Spokane, Clark Citizenship: U.S. Citizens 89%, Lawfully Present in the U.S. 11% Employment: Employed 45%, Unemployed 55% MONTHLY ENROLLMENT ACTIVITY Number of applications received: 81 Number of applications approved: 68 Number of applications pended: 1 Number of applications denied: 7 Number of newborns enrolled: 0 Primary denial reason: creditable coverage within the last six months Percent of applications submitted by agents: 9% Percent of applications qualifying by evidence of pre-existing condition: 83% Percent of applications qualifying by submittal of denial letter or rider: 17% Terminations in the reporting month: 15 Notable comparisons/observations: The number of applications received increased by 15% from August to September. 1

2 MONTHLY CLAIMS EXPENSE Medical Claims Paid: $1,107,138 Pharmacy Claims Paid: $445,469 Estimated Claims Incurred But Not Paid: $4,057,000 OTHER MONTHLY ACTIVITY Claims Activity: Number of claims received: 1,89 Claims inventory: Received but not adjudicated 145 / Pended 69 Number of EHIP claims received: 30 Total dollars paid on EHIP claims: $91, Customer Service Telephone Calls and Website Visitors: Average calls per day: 47 Average website visitors per day: 7 Notable observations/comparisons: The majority of calls are regarding verification of benefits. We continue to receive a significant number of calls regarding Health Care Reform as well. Appeals: Number of appeals received related to eligibility: 0 Number of appeals received related to other: 3 Number of appeals adjudicated in favor of applicant/enrollee: 3 Number of appeals adjudicated and denied: 0 Administrator s Levels of Service: X Administrator met all levels of service. Administrator did not meet the following levels of service:

3 Monthly Operations Report Monthly Operations Report September 011

4 Enrollment Activity September 011 PPO $,500 PPO $ PPO $500 PPO $,500 Received PPO $,500 Applications Received in the Reporting Month Applications Approved in the Reporting Month* PPO $ PPO $500 PPO $,500 Approved *Approved applications include applications that were pended prior to the reporting month for effective dates prior to the reporting month. PPO $,500 PPO $500 Applications Pended in the Reporting Month PPO $500 PPO $,500 Pended 10 Reasons September Statistics Pending Denied No Signature No Proof of Residency 17% No Rejection Letter 4% No Voided Check No Bank Authorization (for EFT's only) 8% "Other" Condition Marked, but no Diagnosis Code Physician's Statement Incomplete Application No Premium Payment 8% No Proof of Citizenship 5% No Pre-existing Condition 43% Creditable Coverage within the last 6 months 57% Withdrawn Total Total Applications Denied Clean App Turn Time 7 3 ID Card Issuance Turn Time Closed for Lack of information (total) Percentage of clean apps received 5 8% 48%

5 Plan & Age Distribution Summary September 011 This report does not reflect people who enrolled with future effective dates. PPO Plan Age $500 $, Total Total Enrollment = 586 3

6 EHIP Plan & Age Distribution Summary September 011 This report does not reflect people who enrolled with future effective dates. PPO Plan Age $500 $, Total 10 0 Total Enrollment = 10 4

7 Terminations by Reason (May September 011) 9 NOTE: This chart depicts the reasons why coverage was terminated for enrollees. Non-payment does not reflect the actual reason for termination. At the time of termination for non-payment, the administrator queried the member for the actual reason. "Insured Request" indicates those who did not state a reason for terminating. 8 38% % 9% 6 46% 9% Number of Enrollees % 3% 31% % 4 1 5% 0 Insured Request Deceased Non-Payment Other Insurance Moved out of State Monthly totals may not total 10 due to rounding. May June July August September 5

8 Claims Received October September 011 Average Claims Received = ,900 1,800 1,700 1,600 1,500 1,400 1,300 1,00 1,100 1, ,839 1,89 1,370 1,453 1,346 1,11 1, Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 June-11 July-11 Aug-11 Sept-11 6

9 Average Pre-Registered Claims = 9 Average Pended Claims = 59 Pre-existing Condition Insurance Plan - Washington State (PCIP-WA) Claims Inventory October September Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 June-11 July-11 Aug -11 Sept-11 Pre-Registered Pended 7

10 High Dollar Paid Claims Report October September 011 Month / Year Case Provider Total Billed Total Paid Date of Service Received Date Paid Primary Diagnosis October November 010 None December 010 None January 011 None February 011 None March April May None Harrison Medical Center $177, $159, /1/10-09/7/10 10/06/10 10/6/ Coronary Athrosclerosis of Native Coronary Artery Sacred Heart Medical Center $457,354.5 $39, /18/11-0/3/11 03/03/11 03/3/ Septicemia NOS Swedish Medical Congenital Insufficiency of Center - Cherry Hill $0, $148, /7/11-0/03/11 03/10/11 03/9/11 Aortic Valve PeaceHealth St. Joseph Med Center $171, $16, /17/10-1/31/10 01/1/11 04/08/ Acute Respiratory Failure Harborview Medical Center $11,14.81 $79, /04/11-03/07/11 03/18/11 04/19/11 5. Cerebral Meninges Virginia Mason Medical Center $88,53.8 $70, /03/11-0/19/11 03/09/11 04/07/ Benign Neoplasm - Colon June Johns Hopkins Hospital $355, $7, /3/11-5/19/11 06/14/11 06/30/11 July 011 August 011 None None September Deaconess Medical Center $11,16.37 $73, /1/11-4/15/11 06/01/11 06/09/ Vascular complications of mesenteric artery 7.1 Displacement of lumbar intervertebral disc without myelopathy Sacred Heart Medical Center $16, $67, /0/11-07/1/11 08/0/11 09/0/ Congestive heart failure Tacoma General v58.11 Encounter for AllenMore $6,85.0 $54, /05/11-08/10/11 08/18/11 09/07/11 antineoplastic chemotherapy Average Amount Average Amount Billed: $160,148.7 Paid: $110,661.9 Includes claims with paid amounts $100,000 through March 011 and $50,000 from April 011 on. 8

11 Average Calls & Web Site Visitors Per Day October September 011 Average Telephone Calls Per Day = 33 Average Web Site Visitors Per Day = Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 June-11 July-11 Aug-11 Sept-11 Telephone Contacts Web Site Visitors 9

12 Call Types October September 011 Insd / Prov Inquiry Type Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 June-11 July-11 Aug-11 Sept-11 Monthly Average Appeals Explanation of Appeals Process / Status of Appeal Benefit Information Plan Inquiry Benefit Information Health Care Reform Billing Finance Issues / Premium Due / Rates / Billing Status Claims Claim Status Claims EOB Questions Claims Response to letter Claims Other Enrollment Application Status Enrollment Member Eligibility / ID Card RX Inquiry Benefit Question / Filing Claims TOTAL PB & E Inquiry Type Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 June-11 July-11 Aug-11 Sept-11 Monthly Average Appeals Explanation of Appeals Process / Status of Appeal Benefit Information Plan Inquiry Benefit Information Health Care Reform Billing Finance Issues / Premium Due / Rates / Billing Status Claims Claim Status Claims EOB Questions Claims Response to letter Claims Other Enrollment Application Status Enrollment Member Eligibility / ID Card RX Inquiry Benefit Question / Filing Claims TOTAL

13 October September 011 Levels of Service Contractual Levels of Service Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 June-11 July-11 Aug-11 Sept-11 Enrollment Standards day Clean Application Process day ID Card Issuance Accuracy 99% Billing Standards day Paid-to Status Update Accuracy 99% Claims Standards Notification day Clean Claim Process Clerical Accuracy 98% % % % 99.8% 9. Financial Accuracy 99% % % % Overall Processing Accuracy 97% % % % 10 Customer Service Standards Sec. Speed of Answer 60 sec % Abandonment Rate 5% 1% 1% % % % 1% % % 1% 3% % 1% 13. Accuracy 95% % % Premium Refunds 99% N/A N/A Updates posted w/in 48 hours Standard 1 - If the date received compared to the date approved for all clean applications approved during the reporting month is less than 14-days. Standard - If the date received compared to the date mailed for all applications approved during the reporting month is less than 30-days from receipt of eligible application to issuance of identification card. Standard 3-99% or greater accuracy rate for enrollment coding of premium, plan and age rate categories for all approved applications during the reporting month. Standard 4-10 scoring of (5) member audit of 14-calendar days or less from premium receipt to update of eligibility file paid-to-status. Standard 5-99% scoring of (5) member audit of accuracy for posting of correct payment, implementation of rate changes and premium account reconciliations during the reporting month. Standard 6-10 notification for all claims not paid within 10-business days during the reporting month. Standard 7-10 of clean claims processed within 30-calendar days during the reporting month. Standard 8-98% or greater accuracy rate for clerical coding of claims based on a 5% claim audit during reporting month. Standard 9-99% or greater accuracy for benefit and payment of claims based on a 5% claim audit during reporting month. Standard 10-97% or greater overall claims processing accuracy for benefit and payment of claims based on a 5% claim audit during reporting month. Standard second or less average speed of answer for all telephone inquiries received during the reporting month. Standard 1-5% or less call abandonment rate. Standard 13-95% or greater accuracy based on a % enrollee audit for accuracy of customer service response to inquiry during the reporting month. Standard 14-99% or greater of premium refunds issued (or checks returned) within 15 days of all ineligible and denied applications based on a % enrollee audit during reporting month. Standard responsible for posting web site updates within 48 hours of receipt. 11