Learning & Informatics Summit

Transcription

1 Learning & Informatics Summit 2016 Optimizing the Delivery of Oral Healthcare and Capturing Incremental Savings with Smart Claim Selection P&R Dental Strategies, LLC

2 Smart Claims Selection as part of the Optimized Enterprise Solutions PRICE/ AFFORDABILITY Commoditization Price Driven QUALITY Multiple Benchmarks PROFITABILITY CLIENT SATISFACTION (The Group) PROVIDER SATISFACTION/ RETENTION/ ENGAGEMENT Network Requirements (Adequacy, Accuracy, ECP) MEMBER SATISFACTION Consumer Driven Consumer Changes (Millennials)

3 A Delicate Balancing Act Perception Cost containment/claim review is not perceived favorably by members and providers Provider Satisfaction vs Price When deployed in an efficient manner claim review can lead to improvements in provider satisfaction

4 A Paradigm Shift Cost Containment The best friend of the doctors that practice within the norm;; reduces the hassle factor

5 Learning & Informatics Summit 2016 Manual Resource Management Strategies

6 Traditional Claim Review Focus BY PROCEDURE TYPE All Crowns All Fixed Bridges All Impactions All SRP All Implants BY FOCUSED REVIEW OF A PROVIDER All claims for Dr. X All procedure types

7 Claims Selection Focused on Outlier Behavior Examples: BASED ON MULTIPLE PROCEDURES Multiple Impactions (e.g., Prophylactic removal in patients age 16 and under) Multiple Quadrants of Scaling & Root Planing (e.g., Age 30 or younger) Multiple Surgical Extractions (e.g., History of perio surgery, Planned Denture) Multiple Fixed Bridges/Implants (Any) BASED ON OUTLIER BEHAVIOR OF PROVIDER Crowns with Outlier Behavior (Upcoding or Over-Utilization) Multiple Amalgams/Composites or Multiple Surface Restorations with Outlier Behavior (Upcoding, Over-Utilization or Unbundling)

8 Outcome Standard Referral Guidelines Focused Review Many claims are reviewed unnecessarily Claims process slowed down longer resolution for docs and members Dr. Johnson and Dr. Smith both provided documentation for review on all of the claims (Hassle factor) Risk: Provider Satisfaction Reviewing all of anything is not efficient Too much time reviewing and approving claims is a strain on resources and bothersome to the network

9 Selection/Screening: Directing the Right Claims to Clinicians How do organizations deal with volume growth when the team is already overwhelmed? Processor or Para-professional Clinicians The Risk? More people in the mix means more reliance on subjective judgement.

10 Learning & Informatics Summit 2016 Smart Claims Selection Basics

11 Smart Claims Selection A smart phone appears intelligent because it has elements of a computer combined with traditional phone functions. A smart home appears "intelligent" because its computer systems can monitor so many aspects of daily living. Smart Claims Selection Statistics and the power of the Big Data contained in DentaBase make intelligent choices that are not visible to traditional reviewers and prioritize where to spend your time and resources to the greatest effect.

12 The Most Powerful Claims Selection Tool Rules combining key areas of abuse with the cross-payer database deliver the power to detect outlier behavior. Rules Database Outlier Detection This type of rule is focused on determining probability based on the provider profile and denial rate for each code that has a rule.

13 Big Data in Smart Claims Selection With Data Bigger is Better Small Dataset = Limited Insights Big Dataset = Statistically Credible Insights Sequence Matters INPUT Daily Electronic Claim Feed Weighted Algorithms OUTPUT Electronic List of Claims Rank Ordered by Savings Probability

14 Learning & Informatics Summit 2016 Efficiency Gains Through Smart Selection

15 Cons DAILY CAPACITY: 100 TODAY S CROWN CLAIMS: 20 Claim Claim Claim Claim

16 Cons DAILY CAPACITY: 100 TODAY S CROWN CLAIMS: 100 Claim Claim Claim Claim Claim Claim Claim Claim Claim Claim Claim Claim Claim Claim Claim Claim Claim Claim Claim Claim

17 Cons DAILY CAPACITY: 100 TODAY S CROWN CLAIMS: 190 Claim Claim Claim Claim Claim Claim Claim Claim Claim Claim Claim Claim Claim Claim Claim Claim Claim Claim Claim Claim

18 Cons Clai m 1 DAILY CAPACITY: 100 TODAY S CROWN CLAIMS: 200 SMART SELECTIONS: 15 Claim Claim Claim Claim Claim Claim Clai m Clai m Claim Claim Clai m 46 Claim Clai m Claim Claim Clai m Claim Claim Claim

19 Learning & Informatics Summit 2016 The Pronto Basics

20 Where s the Sweet Spot? 5 Medium Risk High Risk 4 Financial Risk Index 3 2 Share Low Risk Mitigate & Control Medium Risk 1 Accept Control Overall Abuse Index

21 Dummies Guide to how a Pronto claim is scored Net Payable Amount = Score Real time financial risk assessment prior to payment Provider Practice Pattern Profile = Score Claim Summary Score Provider Procedure Denial Rate Profile = Score Rules Engine = Score Claim summary scores are calculated on the selected claims from the daily claim volume Learning & Informatics Summit 2016

22 The Pronto Workflow

23 The General Pronto Workflow There are 4 distinct parts of the workflow process The front end adjudication (completed by the Client) Daily File is sent to P&R Pre-payment adjudication claims are sent to P&R daily (before the final payment is made) and Pronto selects and flags the claims that should be reviewed prior to payment The claims are returned to the Client to be directed for consultant review or processor action and completion of the claims review, processing, payment and denial process. Monthly File is sent to P&R Final adjudication of all claims completed within the data month are added to DentaBase and monthly reconciliations are completed to support performance reporting.

24 Part 1 - Pronto Workflow 1 The front end adjudication (completed by the Client) Claims are Mailed or Submitted to the Payer Provider Contract and Member Benefits are Calculated Standard Business Edits are performed Daily claims file is procedure

25 Part 2 - Pronto Workflow 2 Pre-payment adjudication claims are sent to P&R daily (before the final payment is made) and then Pronto selects, ranks, and flags the claims that should be reviewed prior to payment Daily Claims file is transmitted to P&R (by the Client) Pronto rules are run and claims are selected and ranked for review

26 Part 3 - Pronto Workflow 3 The claims are returned to the Client for appropriate review or action Claims selected for Clinical review are transmitted back to client OR Claims selected for clinical review can be transmitted directly to P&R s Claim Review Management System and reviewed by P&R consultants Claims selected for Processor action are transmitted back to client Claims NOT selected for are transmitted back to client

27 Part 3 Final Actions Are Completed by the Client a. Claims NOT selected are released to complete the adjudication and payment cycle (by the Client) b. Claims that ARE selected for consultant review are routed to consultants for review c. Claims that ARE flagged with Processor rules are routed to Processors for completion.

28 Part 4 - Pronto Workflow 4 Monthly File is sent to P&R Final adjudication of all claims completed within the data month are added to DentaBase and monthly reconciliations are completed to support performance reporting Monthly Claims file is transmitted to P&R Dental Strategies Monthly claims file loaded into DentaBase P&R Dental Strategies Completes Monthly reconciliation report and performance review

29 Learning & Informatics Summit 2016 Examples: The Impact of Supplementing Your Current Process

30 Supplementing Your Edit Capabilities An example of a Processor Rule: Rule 47D: A full mouth X-ray is unbundled and multiple X-rays performed on the same date of service as the full mouth X-ray are billed separately. Rule ID Send To Procedure Type Procedure Code 47D Processor X-Rays 0220, 0230, 0270, 0272, 0273, 0274, 0277 Rule Description Select if on the same claim, same DOS as Reason for Selection Deny periapical and bitewing radiographs submitted on same date of service as a complete series of radiographs. Processor Rule: Does not require consultant review as a clinical decision does not have to be made.

31 Real Case Examples of Supplemental Cost Containment in Claims Expenditures Edits supplemented with smart claims selection based on processor rules Company A $491,899 Incremental savings Company B $1,534,648 Incremental savings Company C $3,583,040 Incremental savings Company D $5,311,287 Incremental savings

32 Samples of Supplemental Rules D two separate one surface fillings are submitted on the same tooth for different surfaces, same DOS for teeth #'s 6-11, 22-27, c-h, m-r D4910 Perio Maintenance submitted with no history of scaling & root planning or periodontal surgery D7140, D7210 Extractions billed for tooth in arch with history of full complete denture Company A $357k in annual savings Company B $830k in annual savings Company C $476k in annual savings

33 Directing Claims to the Right Place An example of a Dental Consultant Rule: Rule 3G: Providers often know the payer s review guidelines which frequently don t include single crown submissions. Treatments performed for multiple crowns on the same date of service are submitted on separate claims. Rule ID Send To Procedure Type Procedure Code 3G Consultant Crowns 27* except 2799 and/or 296*for teeth #s 1-32, a-t Rule Description Select for review if 2 or more crowns (27* excluding 2799) and/or veneers (296*) are submitted on separate claims for predetermination or with same DOS. Reason for Selection Crowns and/or labial veneers submitted on separate claims for predetermination or same date of service to avoid UR Consultant Rule: This type of rule requires a clinical decision and is therefore sent to a consultant.

34 Smarter Claims Selection Focuses on the Outliers and Impacts Future Behavior Percentage of Dollar Savings From Projected Paid Amount Current Clients 50.5% 20.8% 10.1%

35 Sample Rules for Outlier Behavior Posterior Composites Select when provider is an outlier behavior in specific ratios related to three surface posterior composites Company A $276k in supplemental savings Company B $223k in supplemental savings

36 Additional Rule Examples Outlier Behavior 11D 12D 22AF 22Q 26H 27R Provider Denial Rate Outlier for D4260, D4261 Osseous Surgery Provider Denial Rate Outlier for D4249 Crown Lengthening Provider Outlier Ratio Score on D2161 (MODB, MODL, MODF surfaces only in any order) Amalgams Provider Outlier Ratio Score on D2391 Posterior Composites Provider Outlier Ratio Score on D7220 Impactions Provider Outlier Ratio Score on D7510, D7511 Incision and Drainage 31A Provider Outlier Ratio Score on D2929, D2930, D2931, D2932, D2933, D2934 Prefabricated Crowns 35B Ratio ScoreD3220 Therapeutic Pulpotomy 37N 3B 4B 6C Provider Outlier Ratio Score on D9940 Occlusal Guard Provider Outlier Ratio Score on D27* except D2799 for 1-32, a-t Crowns Provider Outlier Ratio Score on D2960, D2961, D2962 Veneers Provider Denial Rate Outlier for D3346, D3347, D3348 Root Canal Retreatments

37 Real Case Examples of Supplemental Cost Containment in Claims Expenditures Current Review Process supplemented with smart claims selection 100 additional claims per day Company A $2,727,186 Company B $4,885,608 Company C $5,982,926 Outcomes vary by company based on company specific processes, policies and procedures.

38 Case Study 1: Incremental Savings- Consultant Review (100 Additional Claims Per Day) Part of Historical Savings Not Selected by Pronto Selected by Both Historical Process and Pronto Additional Savings - Pronto Selected Total Savings: $5.2 Million (35,000 Claims) Total Savings: $1.2 Million (22,130 Claims) Total Savings: $5.6 Million (24,800)

39 Case Study 2: Incremental Savings Consultant Review (~ 700 Claims Per Day) Part of Historical Savings Not Selected by Pronto Selected by Both Historical Process and Pronto Additional Savings - Pronto Selected Total Savings: $25,826,327 (123,353 Claims) Total Savings: $2,916,738 (29,120 Claims) Total Savings: $33,662,675 (180,763 Claims)

40 Pronto Consultant (Clinical Review) Selections (Small No Prior Claim Review) By Procedure Type 4 Full Bony Impactions $292k Posterior Composites $252k Anterior Crowns $216k Crowns (3+) $110k Scaling & Root Planing $158k Implants $67k v.1.0e

41 Pronto Consultant (Clinical Review) Selections (Mid-Size with Current Claim Review) By Procedure Type Crowns & Veneers $993k Bridges $280k Posterior Composites $99k Scaling & Root Planing $70k v.1.0e

42 Pronto Consultant (Clinical Review) Selections (Large with Current Claim Review) By Procedure Type Impactions $8.4 million Composites $4.7 million Anesthesia $808k Onlays $674k Scaling & Root Planing $1.4 million Amalgams $544k v.1.0e

43 Learning & Informatics Summit 2016 Golden Rules

44 The Golden Rules The Golden Rules are the common rules across all Pronto clients that have: the highest procedure selection; and the highest attributed savings.

45 Golden Rules 3D, 26B, 3O, 17A, 25B, 3B 3D - Multiple anterior crowns or veneers possibly indicating cosmetics. 26B - Four full bony impactions D7240 submitted on same claim for same DOS or pre-determination. 17A - Scaling and Root Planing D4341 or D4342 performed on patients 30 years of age and under. 25B - Provider Outlier Ratio Score on D7210 Surgical Extraction 3B - Provider Outlier Ratios Score on Crowns 3O - Crowns and/or labial veneers and/or onlays submitted on the same claim for pre-determination or same date of service.

46 Learning & Informatics Summit 2016 Monthly Reconciliation and Performance Review

47 Daily Selection Viewer

48 Sample Monthly Reconciliation Report P&R Reconciliation - Unfiltered P&R Reconciliation - Filtered Additional Savings Opportunity (Above Current Threshold - above 1,075 claims per day) (Rolling 12 Months) (May April 2016) (Rolling 12 Months) (May April 2016) 25 more selections per day 100 more All additional selections per day selections # Consultant Rule Selections 498,061 59, ,732 8,011 # Processor Rule Selections 8,000 3,100 Total # of Claims Pronto Consultant Rules 163,021 24, ,874 4,998 Total # of Claims Tag- Alongs 172,698 35, ,272 3,571 Total # of Claims Processor Rules 8,720 2,792 Pronto Rule Savings $24 million $11.5 million $10k $38k $93k Tag Along Savings $12 million $5 million $5k $21k $63k Must Review Savings Total Savings $36 million $17 million $16k $59k $157k

49 Golden Rule Optimization Feedback Golden Rule Optimization (shaded rules are on) 3B 3D 3O 17A 25B 26B The monthly performance review will include quantification of additional savings opportunity specifically related to Golden Rules that may not be turned on.

50 Learning & Informatics Summit 2016 Take it One Step Further as part of Enterprise Solution

51 An optimized solution to manage critical success factors Focus on the outliers Concentrate on the pretreatment review of the outliers and use the smart selection to monitor changes in behavior over time. Increase auto adjudication rates of the claims from providers that are not outliers 51

52 An optimized solution to manage critical success factors Provider Satisfaction Same benefits of rewarding good players through reduced hassle factors and concentrating resources on the outliers. WHILE STILL ENGAGING BEFORE TREATMENT IS COMPLETED. POWERFUL SENTINEL EFFECT. Client Satisfaction Controlled cost containment to lower premiums. 52

53 Take it one step further Reward providers that are continuously practicing within the program norm and services are routinely approved don t have to send in records any more unless requested Same safety net monitoring, profiling, smart claims selection AND you reinstate the requirement if change in behavior. Use profiling to narrow the network participation and eliminate the inclusion of providers that demonstrate outlier behavior. 53

54 Enterprise Performance Optimizer Solution Network Recruitment Network Management Claims Actuarial!!!! ANY WILLING PROVIDER CONDONING ABUSIVE BEHAVIOR FASTER PAYMENT OF UNWARRANTED CLAIMS NON-COMPETITIVE DENTAL PRODUCTS Target the Right Dentists with the Right Discounts Manage Financial Risk of Abusive Behavior Dynamic Claim Review Selection Rank Order Probability of Savings Competitive Pricing/ New Products powered by DentaBase INCREASED EFFICIENCES/$$ SAVINGS TO PAYER v.1.0e

55 Thank You! Learning & Informatics Summit 2016 For more information