ACHIA Operations Report

Transcription

1 Monthly Operations Report ACHIA Operations Report January 209

2 Levels of Service February January 209 Levels of Service Feb-8 Mar-8 Apr-8 May-8 Jun-8 Jul-8 Aug-8 Sep-8 Oct-8 Nov-8 Dec-8 Jan-9 Enrollment Standards. 4-day Clean Application Process 00% 00% 00% 00% 00% 00% 00% 00% 00% 00% 00% 00% 00% 2. 4-day ID Card Issuance 00% 00% 00% 00% 00% 00% 00% 00% 00% 00% 00% 00% 00% 3. Accuracy 99% 00% 00% 00% 00% 00% 00% 00% 00% 00% 00% 00% 00% Billing Standards 4. 4-day Paid-to Status Update 00% 00% 00% 00% 00% 00% 00% 00% 00% 00% 00% 00% 00% 5. Accuracy 99% 00% 00% 00% 00% 00% 00% 00% 00% 00% 00% 00% 00% Claims Standards day Clean Claim Process 00% 00% 00% 00% 00% 00% 00% 00% 00% 00% 00% 00% 00% 7. Clerical Accuracy 97% 00% 00% 00% 00% 00% 00% 00% 99.8% 99.9% 00% 00% 00% 8. Financial Accuracy 98% 00% 00% 00% 00% 00% 00% 00% 99.9% 99.9% 00% 00% 00% Customer Service Standards Sec. Speed of Answer* 45 sec avg % Abandonment Rate* < 5% 0.0% 0.0% 0.9% 2.4% 3.2% 4.9% 4.2% 0.0% 0.9%.2%.3%.6% * Reporting began January, 2007 Measurement of Standards Standard - If the date received compared to the date approved for all clean applications approved during the reporting month is less than 4-days. Standard 2 - If the date received compared to the date mailed for all applications approved during the reporting month is less than 4-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 4-00% scoring of (0) member audit of 4-calendar days or less from premium receipt to update of eligibility file paid-to-status Standard 5-99% scoring of (0) member audit of accuracy for posting of correct payment, implementation of rate changes and premium account reconciliations during the reporting month. Standard 6-00% of clean claims processed within 30-calendar days during the reporting month. Standard 7-97% or greater accuracy of a (20) claim audit for proper clerical coding of claims during the reporting month. Standard 8-98% or greater accuracy of a (20) claim audit for proper clerical coding of claims during the reporting month. Standard 9-45 second or less average speed of answer for all telephone inquiries received during the reporting month. Standard0-5% or less call abandonment rate.

3 Number of Claims Received February January 209 (as compared to Previous Year) Feb- 7 Feb- 8 Mar- 7 Mar- 8 Apr- 7 Apr- 8 May- May- 7 8 Jun- 7 Jun- 8 Jul- 7 Jul- 8 Aug- 7 Aug- 8 Sep- 7 Sep- 8 Oct- 7 Oct- 8 Nov- 7 Nov- 8 Dec- 7 Dec- 8 Jan- 8 Jan- 9 2

4 Service Code Analysis* For the Month of January 209 Submitted PPO or Other Deductible Coinsurance Total Claim Code Description Charge Discount Ineligible Amounts Amounts Paid Lines ANCILLARY CHARGES $ 260, $ 39,59.92 $ - $ - $ - $ 22, ANESTHESIA $, $ - $, $ - $ - $ 7.52 PART B CO-INSURANCE $ 4,656, $ 5.52 $ 4,555, $ - $ - $ 00, CHIROPRACTIC $ 2, $ - $ 8.00 $ $ $, DIAGNOSTIC TESTING $ 8,650.7 $ 2,29.35 $ $ - $ $ 6, ER PHYSICIAN $ 2,7.00 $ $ - $ - $ 26.2 $, EMERGENCY ROOM $ 4, $,32.30 $ - $ - $ - $ 3, INJECTIONS $ 9.00 $ - $ - $ - $ - $ 9.00 IMMUNIZATIONS $ $ 23.6 $ - $ - $ - $ MISC CHARGES $ 9, $ - $ 3, $ 6.99 $ 2.78 $ 5, MAMMOGRAM $ $ 0.35 $ - $ - $ $ M/N OUTPATIENT $ $ - $ $ 6.8 $ - $ - OFFICE VISIT $,53.5 $ $ 2,886.6 $, $ $ 7, PHYSICAL THERAPY $ $ - $ $ $ - $ - PRESCRIPTION DRUGS $ 86,36.5 $ - $ - $ 26, $ 5, $ 53, SURGERY $ 3,2.00 $ - $ $ - $ - $ 2, UB DIAG TESTING $ 8, $, $ - $ $ $ 6, WELLNESS EXAM $ $ - $ - $ - $ - $ WELLNESS TESTING $ $ 6.56 $ - $ - $ - $ TOTALS $ 5,057,06.68 $ 45,6.76 $ 4,564, $ 28, $ 6,360.2 $ 42, * Represents claims adjudicated in the month. May not tie to the financials depending on the timing of voids and adjustments. 3

5 Service Code Analysis Year to Date January - December 208 Submitted PPO or Other Deductible Coinsurance Total Claim Code Description Charge Discount Ineligible Amounts Amounts Paid Lines ANCILLARY CHARGES $ 6,62, $ 696,454.7 $ 2,390, $ 4, $ 6, $ 3,54,39.45,972 AMBULANCE $ 0,83.08 $, $ 69.3 $ $ $ 7, ANESTHESIA $ 6, $ $ 7,28.28 $ - $ $ 8, ASSISTANT SURGEON $ 5, $ 2,52.07 $ 2,449.4 $ $ 2.78 $ AIR TRAVEL $ $ - $ - $ - $ - $ PART B CO-INSURANCE $ 48,850, $ 4, $ 48,99,969.8 $ - $ - $ 646, ,0 CHIROPRACTIC $ 46, $, $ $, $, $ 4, D/A OUTPATIENT $ $ $ - $ - $ - $ DIAGNOSTIC TESTING $ 833, $ 30,68.0 $ 589, $ 7, $ 9,095.4 $ 97, ER PHYSICIAN $ 2, $ $ 0, $ $ $ 9, EQUIPMENT $ 8, $ $ 4, $, $ $, EMERGENCY ROOM $ 34,50.84 $ 5, $ 2, $ - $, $ 25, HOME HEALTH CARE $ 4, $ $ - $ $ 0.97 $ 3, HOME HEALTH MISC. $ 52, $ 5, $ - $, $ 2, $ 33, HOSPITAL INPT VISIT $ 32, $ - $ 30,73.69 $ $ $, INTENSIVE CARE UNIT $ 74, $ - $ 7, $ $ $, INJECTIONS $ 80, $,98.4 $ 25, $ $, $ 42, IMMUNIZATIONS $ 2, $ $ - $ - $ - $ 2, MISC CHARGES $ 200, $ 2,05.0 $ 76, $ 5, $,83.28 $ 4, MAMMOGRAM $ 4,67.73 $ 2.0 $ $ $ - $ 4, M/N OUTPATIENT $, $ 8.95 $ $ $ $ MORBID OBESITY $ $ - $ - $ - $ - $ MULTIPLE SURGERY $ 7,292.8 $ 8,35.76 $, $ 2,30.74 $ $ 5, M/N IP VISIT $ $ - $ $ - $ 24.6 $ MASSAGE THERAPY $ $ - $ - $ - $ - $ OFFICE VISIT $ 83, $ 5, $ 8, $ 7, $ 3,79.60 $ 48, PRIVATE ROOM $ 62, $ - $ 59, $ - $ $ 2, PHYSICAL THERAPY $ 24, $ 2, $ $ 4, $, $ 6, PRESCRIPTION DRUGS $ 624, $ - $ - $ 53, $ 37,496.0 $ 533,66.00,767 SURGERY $ 255,484. $ 8,58.4 $ 97,858.0 $ 7,38.2 $,360.5 $ 40, SEMI-PRIVATE ROOM $ 79,255.6 $ - $ 76,599.6 $ - $ $ 2, UB ANESTHESIA $ 5,470.0 $ 2,85.25 $ - $ - $ $ 2, UB DIAG TESTING $, $ - $ 4,566.4 $ 4,4.67 $ 76, UB PHYSICAL THERAPY $ $ - $ - $ - $ UB SURGERY $ 4, $ - $ - $ $ 6, UB CANCER THERAPIES $, $ - $ - $ - $, UB PULMONARY REHAB $, $ 40.9 $ - $ 86.9 $ WELLNESS EXAM $ 4,39.34 $ $ 7.00 $ $ WELLNESS TESTING $ 6,847.0 $ 3, $ $ $ TOTALS $ 58,496, $ 823, $ 52,069, $ 5,64.67 $ 86, $ 5,40,722.30,773 4

6 RANK Top Provider Report For the Month of January 209 DESCRIPTION # OF CLAIMS SUBMITTED CHARGES PAID BY PLAN RENAL CARE GROUP ALASKA INC 2 $ 734, $ 229, ST ELIAS SPECIALTY HOSPITAL $ 702,356.6 $ 45, LIBERTY DIALYSIS ALASKA 9 $ 2,238,784.0 $, PROVIDENCE HEALTH & SERVICE WASHINGTON 9 $ 362,824.8 $ 0, DENALI DIALYSIS 7 $,464,88.30 $ 7, DIALYSIS ASSOCIATES OF ALASKA 32 $ 53,45.00 $ 6, PROVIDENCE CONTINUING CARE $ 68, $ 3, CLARIBEL TAN MD 7 $ 3, $ 3, HAWAII LIFE FLIGHT LLC 3 $ 26, $ 3, GALEN HOSPITAL ALASKA INC 6 $ 72, $ 3,39.70 REHABILITATION MEDICINE ASSOCIATES 4 $, $ 3, MAYO CLINIC HOSPITAL-ROCHESTER 5 $ 44,74.20 $, SOUTH PENINSULA HOSPITAL INC 6 $ 7,04.00 $, ALASKA HEART INSTITUTE LLC 2 $ 2, $, SWEDISH HEALTH SERVICES $ 87, $, LAWRENCE E GREEN MD $ 3, $, ALASKA EMERGENCY MEDICINE ASSOCIATES 5 $ 4,88.00 $, ALASKA HOSPITALIST GROUP LLC 22 $ 23,42.00 $, KIDNEY AND HYPERTENSION CLINIC 58 $ 38, $, GOLDEN HEART EMERGENCY PHYSICIANS 2 $ 3, $ WASILLA RENAL CARE GROUP LLC 3 $ 238, $ SPINE AND JOINT REHABILITATION 4 $ $ PROVIDENCE IMAGING CENTER 9 $,46.00 $ ALASKA RETINAL CONSULTANTS 2 $ 6, $ MAT-SU VALLEY MEDICAL CENTER 3 $ 26, $ KETCHIKAN GENERAL HOSPITAL CLINICS 4 $ 3,84.00 $ MAKAR EYECARE LLC $ $ MEDICAL GROUP OF ALASKA 2 $ $ CEDARS SINAI MEDICAL CENTER 5 $ 6, $ PROVIDENCE HEALTH & SERVICES 2 $ 6,28.00 $ Top 30 Total 296 $ 6,674, $ 346,

7 Top Providers Year to Date January - December 208 RANK DESCRIPTION # OF CLAIMS SUBMITTED CHARGES PAID BY PLAN RENAL CARE GROUP ALASKA INC 346 $ 9,738, $ 3,506, LIBERTY DIALYSIS ALASKA 69 $ 9,829, $ 22, PROVIDENCE HEALTH & SERVICE WASHINGTON 275 $ 4,585, $ 06, DENALI DIALYSIS 49 $ 6,406, $ 89, DIALYSIS ASSOCIATES OF ALASKA 394 $ 664, $ 79, GALEN HOSPITAL ALASKA INC 38 $,32, $ 70,9.4 7 ANDRZEJ R MACIEWSKI MD 52 $ 85,53.85 $ 53, GENEVA WOODS PHARMACY INC 35 $ 70, $ 46, ALASKA SPINE INSTITUTE SURGERY 6 $ 66, $ 45, BOND PHARMACY INC 36 $ 56, $ 38,382.7 FAIRBANKS MEMORIAL HOSPITAL 22 $ 499, $ 37, FRANKLIN E ELLENSON MD 68 $ 580, $ 24, EDWIN RHIM MD 58 $ 57, $ 23, SURGERY CENTER OF ANCHORAGE 5 $ 36, $ 23, FRESENIUS MEDICAL CARE 6 $ 4,304, $ 2, SOUTH PENINSULA HOSPITAL INC 55 $ 93, $ 2, MAT-SU VALLEY MEDICAL CENTER 3 $ 394,77.28 $ 20, REHABILITATION MEDICINE ASSOCIATES 23 $ 26, $ 7, ORTHOALASKA LLC 58 $ 86, $ 7, MIDNIGHT SUN ONCOLOGY PARTNERS 23 $ 293, $ 7, FRESENIUS MEDICAL CARE SOUTHWEST 54 $ 4,300,4.53 $ 6, ALASKA HEART INSTITUTE LLC 37 $ 88, $ 5, IMAGING ASSOCIATES LLC 24 $ 36, $ 5, FAIRBANKS CANCER CARE PHYSICIANS 34 $ 286, $ 4, TRUE LIFE CHIROPRACTIC 77 $ 5, $ 4, ALASKA RADIOLOGY ASSOCIATES 9 $ 209,52.00 $ 4, CALIFORNIA REHABILITATION INSTITUTE $ 33, $ 3, PROVIDENCE VALDEZ MEDICAL CENTER 5 $ 5, $ 2, PROVIDENCE IMAGING CENTER 2 $ 37, $ 2, MULDOON DEVELOPMENT PARTNERS 33 $,854, $ 2,884.0 Top 30 Total 258 $ 66,287,46.67 $ 4,528,4.5 6

8 Average Cost Per Non Medicare Plan Claim Paid February January 209 $5,000 $4,500 $4,000 $3,500 $3,000 $2,500 $2,000 $,500 $,000 $500 $0 Feb-8 Mar-8 Apr-8 May-8 Jun-8 Jul-8 Aug-8 Sep-8 Oct-8 Nov-8 Dec-8 Jan-9 $,000 Deductible $,500 Deductible $2,500 Deductible $5,000 Deductible $0,000 Deductible $5,000 Deductible $,000 Std Deductible 7

9 Average Cost Per Medicare Plan Claim Paid February January 209 $,200 $,00 $,000 $900 $800 $700 $600 $500 $400 $300 $200 $00 $0 Feb-8 Mar-8 Apr-8 May-8 Jun-8 Jul-8 Aug-8 Sep-8 Oct-8 Nov-8 Dec-8 Jan-9 Carveout Med Supp A Med Supp I Med Supp F 8

10 PPO Savings Analysis February January 209 PPO Network Charge PPO Discount % of Discount First Choice Health Network $ 6,27,585 $,023,77 6.3% 9

11 (ACHIA) High Dollar Paid Claims Report February 208 -January 209 Month / Year Case Provider Total Billed Total Paid Total OOP Date of Service Date Received Date Paid Primary Diagnosis February 208 March 208 April 208 May 208 June 208 July 208 August 208 September 208 October 208 November 208 December 208 January Month Average Amount Billed: $ Month Average Amount Paid: $0.00 Includes claims with paid amounts $00,000 0

12 Plan Age Distribution Summary January 209 Medicare Plans Traditional Plan PPO Plans Age Carveout Med Supp A Med Supp I Med Supp F Age $,000 Age $,000 $,500 $2,500 $5,000 $0,000 $5, Total 6 78 Total 5 Total TOTAL ENROLLMENT: ; Carveout Med Supp A Med Supp I Med Supp F Traditional $,000 Plan $,500 Plan $2,500 Plan $5,000 Plan $0,000 Plan $5,000 Plan

13 Total Enrollment Activity February January Feb-8 Mar-8 Apr-8 May-8 Jun-8 Jul-8 Aug-8 Sep-8 Oct-8 Nov-8 Dec-8 Jan-9 2

14 Enrollment Activity by Plan - Non Medicare Plans February January Feb-8 Mar-8 Apr-8 May-8 Jun-8 Jul-8 Aug-8 Sep-8 Oct-8 Nov-8 Dec-8 Jan-9 A $000 Deductible B $,500 Deductible C $2,500 Deductible D $5,000 Deductible E $0,000 Deductible F $5,000 Deductible $,000 Std Deductible 3

15 90 Enrollment Activity by Plan - Medicare Plans February January Feb-8 Mar-8 Apr-8 May-8 Jun-8 Jul-8 Aug-8 Sep-8 Oct-8 Nov-8 Dec-8 Jan-9 Carveout Med Supp A Med Supp I Med Supp F 4

16 Enrollment Activity January 209 Month Start Adds Pended Adds* Terms Retro Terms** End Net Change Feb Mar Apr May Jun (3) Jul (2) Aug Sep (2) Oct () Nov (2) Dec Jan Totals since June Enrollment is reported by month of initial effective coverage. * Pended Adds represent pended applications that were approved in the reporting month but have a prior effective date. These enrollees are reported in the row representing initial effective coverage date. **Retro Terms represent terminations that were processed in the reporting month but have a prior termination date. These terminations are reported in the row representing the actual month of the termination. Qualifying Event Reasons (data from 6// - /3/9) No other health insurance - HIPAA eligible Rejection of other health coverage due to pre-existing condition Pre-qualified health conditions on the list Reinstated Total Pended Adds* Count Percent Jan % % % % % 3 - Termination Reasons (data from 6// - /3/9) Free look period Too costly Deceased Lifetime Max Medicare / Medicaid Moved out of state Unknown - Letter sent to request reason for termination Non-payment Obtained other coverage Total Count Percent Jan-9 Retro Terms** 7 % % % % % % % % % - -,032 00% - 2 5

17 Plan Age Distribution - NEW ENROLLMENT January 209 Medicare Plans Traditional Plan PPO Plans Age Carveout Med Supp A Med Supp I Med Supp F Age $,000 Age $,000 $,500 $2,500 $5,000 $0,000 $5, Total Total 0 Total TOTAL NEW ENROLLMENT: 3 REINSTATEMENTS: 0 (Not included in New Enrollment count) 6