ACHIA Operations Report

Transcription

1 Monthly Operations Report ACHIA Operations Report April 20

2 Levels of Service Levels of Service May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- Enrollment Standards. -day Clean Application Process 00% 00% 00% 00% 00% 00% 00% 00% 00% 00% 00% 00% 00% 2. -day ID Card Issuance 00% 00% 00% 00% 00% 00% 00% 00% 00% 00% 00% 00% 00%. Accuracy 99% 99% 00% 00% 00% 00% 99% 00% 00% 00% 00% 00% 00% Billing Standards. -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 6. 0-day Clean Claim Process 00% 00% 00% 00% 00% 00% 00% 00% 00% 00% 00% 00% 00% 7. Clerical Accuracy 97% 99.95% 99.96% 00% 99.96% 00% 99.55% 99.95% 99.77% 99.75% 99.92% 99.95% 99.9% 8. Financial Accuracy 98% 99.99% 00% 00% 00% 00% 99.88% 99.90% 99.8% 98.00% 00% 99.99% 99.79% Customer Service Standards 9. 5 Sec. Speed of Answer* 5 sec avg % Abandonment Rate* < 5%.9% 2.0%.6% 0.9%.7%.6%.2% 2.%.%.6% 2.7% 0.9% * 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 -days. Standard 2 - If the date received compared to the date mailed for all applications approved during the reporting month is less than -days from receipt of eligible application to issuance of identification card. Standard - 99% or greater accuracy rate for enrollment coding of premium, plan and age rate categories for all approved applications during the reporting month. Standard - 00% scoring of (0) member audit of -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 0-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 9-5 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 (as compared to Previous Year),000 2,500 2,000,500, May- May- 2 Jun- 2 Jun- Jul- 2 Jul- Aug- 2 Aug- Sep- 2 Sep- Oct- 2 Oct- Nov- 2 Nov- Dec- 2 Dec- Jan- Jan- Feb- Feb- Mar- Mar- Apr- Apr- 2

4 Service Code Analysis* For the Month of April 20 Submitted PPO or Other Deductible Coinsurance Total Claim Code Description Charge Discount Ineligible Amounts Amounts Paid Lines ANCILLARY CHARGES $ 906,50.8 $ 9,508.2 $ 20, $ 6,80.82 $ 5,57.2 $ 79, AMBULANCE $ 2,52. $ - $ $,052. $ - $, ANESTHESIA $ 5,6.06 $ 2, $ 5,267. $ 2,225.8 $ 78.8 $ 5, ASSISTANT SURGEON $ 28,5.00 $ 9,200.5 $ - $ - $,55.66 $ 7, PART B CO-INSURANCE $ 86,55.6 $ 67.7 $ 795, $ - $ - $ 20, CANCER THERAPIES $ 2,99.00 $ 5,0.65 $, $ - $ 8.57 $ 25, CHIROPRACTIC $, $ - $ 6. $ 6.66 $ 2.60 $,.0 5 D/A OUTPATIENT $ 58.0 $ 5.8 $ - $ 9.29 $ - $ - 2 DIAGNOSTIC TESTING $ 62,8.7 $,00. $,76.8 $ 6,976.7 $,8.0 $ 69, ER PHYSICIAN $ 2,6.66 $ 8.65 $,565.2 $ 7.8 $ 8.9 $ 2.77 EQUIPMENT $,50.25 $ - $ 92.0 $ $.07 $ 2, EMERGENCY ROOM $ 2, $ 88.7 $ - $ - $ 22. $,676.2 HOME HEALTH CARE $ $ - $ $ - $ 75. $ HOME HEALTH MISC. $,86.20 $.28 $ 6.65 $ - $.09 $ 2,677.8 HOSPITAL INPT VISIT $,60.6 $ $ 6, $ - $ $ 6, INTENSIVE CARE UNIT $ 97,25.00 $ 9,68.2 $ - $ - $ - $ 57, INJECTIONS $ 8,52.7 $,5.7 $ 7,89.02 $ 6.2 $.82 $ 8, IMMUNIZATIONS $.52 $ 2.7 $ - $ - $ - $ MISC CHARGES $ 6,72. $ 78.2 $ 8,20.68 $, $ 97.9 $ 5, MAMMOGRAM $ 8.00 $ 6.70 $ - $ - $ - $.0 M/N OUTPATIENT $ 2, $ 02.9 $ - $ 65.0 $,0.0 $, MULTIPLE SURGERY $ (7.8) $ 2, $ 2,8.96 $,9.05 $ (2,620.0) $ (,80.7) 7 M/N IP VISIT $ $ - $ - $ - $ $ MASSAGE THERAPY $ 6.00 $ 6.0 $ - $ - $ - $ OCCUPATIONAL THERAPY $, $,0.27 $ - $ - $ - $, OFFICE VISIT $ 2, $,0.77 $ 5,.8 $ 6,0.66 $ 87.5 $ 8, PHYSICAL THERAPY $ 0,72.00 $ 2,92.5 $,296. $ - $ $ 6, PRESCRIPTION DRUGS $ 277,557.8 $ - $ - $ 2,22.29 $,25.2 $ 25, SURGERY $ 72,8.00 $ 2,982. $ 29,52.2 $ 8,770.5 $, $ 0, SEMI-PRIVATE ROOM $ 72, $ 7,00.56 $,8.00 $ - $ - $ 5,22.00 UB ANESTHESIA $ 5,6.56 $,90.2 $ - $ - $ $, UB DIAG TESTING $ 65, $,695.2 $ - $,89.59 $,068. $ 9, UB PHYSICAL THERAPY $ 0.00 $ 59.0 $ - $ - $ - $ UB SURGERY $,970.0 $,2. $ - $ 2,8.7 $,8. $ 26,57. 7 WELLNESS EXAM $ $ 6.0 $ - $ $ - $ 0.5 WELLNESS TESTING $ 2, $ 9.7 $ - $,2.55 $ - $, TOTALS $ 2,706,58.6 $ 260,25.65 $,2,97.97 $ 67,208. $ 2,6.2 $,029,99.9 2,5 * Represents claims adjudicated in the month. May not tie to the financials depending on the timing of voids and adjustments.

5 Service Code Analysis Year to Date January 20 - April 20 Submitted PPO or Other Deductible Coinsurance Total Claim Code Description Charge Discount Ineligible Amounts Amounts Paid Lines ANCILLARY CHARGES $ 6,, $ 2,90.5 $,25,7.9 $,68.7 $, $,695,29.50,856 ALLERGY INJECTIONS $ $ - $ 6.80 $ - $ 6.60 $ AMBULANCE $ 2,. $ 26, $ 7,29.6 $,96.92 $,2.22 $ 26, ANESTHESIA $ 6,908.7 $ 5,7.56 $,67.07 $,86. $ 2,0.65 $ 5, ASSISTANT SURGEON $ 5,5.0 $ 20,859.0 $ - $ 25.5 $,55.66 $ 2, PART B CO-INSURANCE $ 5,97,80.8 $ 67.7 $ 5,807,72.0 $ - $ - $ 0,050.00,97 CANCER THERAPIES $ 2,20.05 $,686.0 $ 97,62.9 $ - $,99.0 $ 9, CHIROPRACTIC $ 9, $ 7.6 $ 6. $,70.0 $,62.8 $ 6, CARDIAC REHAB $,286.5 $ - $, $ 50. $.50 $.99 D/A OUTPATIENT $ $ 62.5 $ - $ $ - $ - DIAGNOSTIC TESTING $ 669, $ 95,70.7 $ 26,57.9 $ 5,98.90 $ 0,6.7 $ 26,875.82,6 ER PHYSICIAN $ 2, $ 0.0 $ 2, $,625. $ $ 6,0.8 EQUIPMENT $ 9, $ 2,09.8 $ 7, $ 88.2 $,259. $ 8, EMERGENCY ROOM $ 57,97.2 $ 9, $ $,.75 $ 2,2.65 $ 2, HOME HEALTH CARE $ 2, $ 2.25 $ $ - $ $ 2, HOME HEALTH MISC. $ 20, $,978.5 $ 86.5 $ 2,580.7 $,8.96 $, HOSPITAL INPT VISIT $ 92,7.65 $,205.0 $,6.62 $ 6,78.8 $,82.7 $ 8, INTENSIVE CARE UNIT $ 56,69.76 $ 0,77.68 $ 27,567.7 $ - $ $ 28, INJECTIONS $ 22,6.68 $ 9,5.5 $ 80,20.69 $ 7,27.90 $,9.95 $ 90, IMMUNIZATIONS $ 2,79.69 $ 2.20 $ - $ - $ 7.60 $ 2, MISC CHARGES $ 9,07.50 $ 5,52.7 $ 0,96.76 $ 7,265. $,8.8 $ 6, MAMMOGRAM $ 2,72.5 $ $ - $ 8.09 $ 5.90 $ 2,9.0 6 M/N OUTPATIENT $ 7,82.09 $ $,2.2 $ 6,582.6 $,669.8 $, MORBID OBESITY $ 0.00 $ - $ - $ 0.00 $ - $ - MULTIPLE SURGERY $ 2,699.8 $ 6,987.5 $,52.2 $,9.05 $ (2,27.20) $ 2, M/N IP VISIT $,.00 $ - $ - $ $ 2.50 $ 2.50 MASSAGE THERAPY $ $ 6.0 $ - $ - $ - $ OCCUPATIONAL THERAPY $,69.00 $,87.67 $ - $ - $ - $ 2,25. OFFICE VISIT $ 06,999. $,78.27 $ 9,80.8 $,08.79 $,0.8 $ 5, PRIVATE ROOM $ 2,85.0 $ $ - $ - $ - $ 2,565.9 PHYSICAL THERAPY $ 5, $ 5,067.8 $ 8,28.2 $ 2, $,878. $ 28, PRESCRIPTION DRUGS $ 776,6.6 $ - $ - $ 7,9.89 $ 5,872.7 $ 56,96.2 2,08 SURGERY $ 299,09.2 $,96.9 $ 29,58.9 $ 27, $ 6,206. $ 2, SEMI-PRIVATE ROOM $ 2,0.56 $ 2,75.56 $,8.00 $ 5,595.7 $ 2,28.26 $ 85, SPEECH THERAPY $ 2.00 $ 0.00 $ - $ - $ 6.80 $ TRANSPLANT SERVICES $ 26,8.69 $ 70, $ - $ - $ - $ 75, UB ANESTHESIA $, $,265. $ - $ 2,076. $ (72.9) $ 6, UB DIAG TESTING $ 26,77. $ 9,27. $, $ 7,802.0 $ 8,79.8 $ 69, UB SPEECH THERAPY $ 2, $ $ - $ - $ - $ 2,26.0 UB MENTAL & NERV OP $ 6.00 $ - $ 7.62 $ 8.8 $ - $ - UB OCCUP THERAPY $,52.00 $ 57.2 $ - $ - $ - $ 9.76 UB PHYSICAL THERAPY $ 8,0.5 $ $, $ $ - $ 2, UB SURGERY $ 0,80.6 $ 6,606.2 $ - $,72.50 $ 5,02.70 $ 85, UB CANCER THERAPIES $ 5,95.8 $ 7,90.8 $ - $ - $ $ 27, UB PULMONARY REHAB $ 5,0.85 $,65.7 $ - $ $ - $,09.22 UB RESP THERAPY $ 2,627.2 $ 9,69.52 $ - $ - $ - $ 2, WELLNESS EXAM $,80.2 $ 5.05 $ - $,025.5 $ - $, WELLNESS TESTING $ 2,57.92 $ $ 6.95 $ 2,2.2 $ - $ 9, EXCEPTIONS $ 9,879. $ 27,56.86 $ - $ - $ 5,25.02 $ 62, TOTALS $ 7,20,265.0 $,02,8.2 $,69,57.0 $ 0, $ 55,66.2 $,56, ,90

6 RANK Top Provider Report For the Month of April 20 DESCRIPTION # OF CLAIMS SUBMITTED CHARGES PAID BY PLAN RENAL CARE GROUP ALASKA INC 8 $ 8,22.70 $ 25, UNIVERSITY OF WASHINGTON 26 $ 29,988.6 $ 20,966.8 PROVIDENCE HEALTH & SERV WASH 0 $ 29,09.9 $ 77,5.85 LIBERTY DIALYSIS ALSASKA $ 70,895.0 $ 50, BANNERHEALTH 6 $ 52,66.66 $, JENSEN & WRIGHT NEUROLOGICAL $ 9,.00 $, NORTHSTAR RADIATION ONCOLOGY $ 0,60.00 $ 26, MAT-SU VALLEY MEDICAL CTR LLC 7 $ 26,897.7 $ 2,9. 9 ALASKA RADIOLOGY ASSOCIATES 7 $ 22, $ 6, ANCHORAGE WOMENS CLINIC $,6.00 $ 6,567.6 FRANKLIN E ELLENSON MD $ 2,86.00 $ 6, RADIOLOGY SERVICES OF ALASKA I $ 6,50.00 $ 5, CENTRAL PENINSULA HOSP PROV 7 $ 6,06.0 $, GENEVA WOODS PHARMACY INC $ 5,69.2 $, AA PAIN CLINIC INC 6 $, $, INTERNAL MEDICINE ASSOCIATES 0 $ 5,.60 $, ALASKA ONCOLOGY & HEMATOLOGY 6 $, $, SLEEP CENTERS OF ALASKA 7 $,56.05 $,.6 9 ASSOCIATION OF UNIVERSITY PHYS 2 $ 9,29.00 $, PROVIDENCE IMAGING CENTER 9 $ 7,66.00 $ 2, DIALYSIS ASSOCIATES OF ALASKA 8 $ 25,67.00 $ 2, WASHOE MEDICAL CENTER 2 $ 79, $ 2, IRELAND CLINIC OF CHIROPRACTIC 2 $ 2,0.00 $ 2, SPECIALIZED PHYSICAL THERAPY 7 $,78.00 $ 2, ALASKA HOSPITALIST GROUP LLC $ 6,09.00 $ 2, MINIMED DISTRIBUTION CORP 2 $,02.9 $, EAR NOSE & THROAT CLINIC INC $, $, PROVIDENCE ANCH ANESTHESIA MED 5 $ 0,06.00 $, FRESENIUS MED CARE SW ANCHORAG $ 62,5.70 $, FAIRBANKS CANCER CARE PHYS 8 $, $, Top 0 Total 9 $ 2,250,90.00 $ 766,

7 Top Providers Year to Date January 20 - April 20 RANK DESCRIPTION # OF CLAIMS SUBMITTED CHARGES PAID BY PLAN RENAL CARE GROUP ALASKA INC 5 $,6,65.0 $ 869, PROVIDENCE HEALTH & SERV WASH 92 $,979,572.6 $ 57,805.8 UNIVERSITY OF WASHINGTON $ 82,6.05 $ 85,552.8 GALEN HOSPITAL ALASKA INC 29 $,59,96.62 $ 25, LIBERTY DIALYSIS ALSASKA 9 $,28, $ 268, GUARDIAN FLIGHT INC 6 $ 78, $ 202,.96 7 MAT-SU VALLEY MEDICAL CTR LLC 6 $ 26, $ 8, BANNERHEALTH 8 $ 25,.69 $ 78, VROM LLC 5 $ 8,6.00 $ 56, AIRLIFT NORTHWEST $ 60, $ 56,060.0 MIDNIGHT SUN ONCOLOGY INC 2 $ 20,792.5 $ 8, PHOENIX BAPTIST HOSPITAL 2 $ 7,95.78 $ 7,50.2 KETCHIKAN GENERAL HOSP CLINICS 5 $ 9, $ 5,2.02 PROVIDENCE SURGERY CENTERS LLC $,5.90 $, BARTLETT REGIONAL HOSPITAL $ 70,25.98 $ 8, ALASKA ONCOLOGY & HEMATOLOGY 99 $ 7,02. $,75. 7 JENSEN & WRIGHT NEUROLOGICAL 7 $ 98,0.00 $, CENTRAL PENINSULA HOSP PROV 7 $ 26, $ 2, SOUTH PENINSULA HOSPITAL INC 70 $ 70, $ 29, NORTHSTAR RADIATION ONCOLOGY 0 $ 66, $ 26, ASSOCIATION OF UNIVERSITY PHYS 25 $ 5,87.98 $ 25, VALLEY RADIATION ONCOLOGY $ 85,68.00 $ 2, OPTUMHEALTH CARE SOLUTIONS 2 $ 2,29.76 $ 2, ALASKA HOSPITALIST GROUP LLC 9 $ 56,.00 $ 2, ALASKA SURGERY CENTER A HEAL 7 $ 0,98.2 $ 22,6. 26 UPMC PRESBYTERIAN SHADYSIDE $ 27, $ 2,.8 27 ANCHORAGE FRACTURE & ORTHO 8 $ 5,290. $ 20, DIALYSIS ASSOCIATES OF ALASKA 7 $ 6,8.05 $ 7, INTERNAL MEDICINE ASSOCIATES 0 $ 5,82.07 $ 5, ALASKA HEART INSTITUTE LLC $ 97,7.5 $ 5,686.6 Top 0 Total 6 $,50,955. $,7,

8 Average Cost Per Non Medicare Plan Claim Paid $,000 $,500 $,000 $2,500 $2,000 $,500 $,000 $500 $0 May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- $,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 $,000 $900 $800 $700 $600 $500 $00 $00 $200 $00 $0 May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- Carveout Med Supp A Med Supp I Med Supp F 8

10 PPO Savings Analysis PPO Network Charge PPO Discount % of Discount First Choice Health Network $,778,62 $ 2,96,8 25.% 9

11 (ACHIA) High Dollar Paid Claims Report Month / Year Case Provider Total Billed Total Paid May 20 None Total OOP Date of Service Date Received Date Paid Primary Diagnosis June 20 July 20 None None August 20 Matsu Regional Medical Center $66,02. $0, $0.00 5/29/- 6// 7/8/ 8/5/ 58.8 Acute respiratory failure 2 Providence Alaska Medical Center $,05.9 $07, $0.00 6/2/20 7/22/ 8/5/ 27. Atrial fibrillation September 20 October 20 None None November 20 UCSF Medical Center $, $0,98.6 $2, /2/- 9/29/ // /26/ 5.5 Epilepsy w/seizures, EEG of brain December 20 None January 20 Providence Alaska Medical Center $200,85.59 $25,9. $9.58 6/8/- 6/2/ 2/26/ /29/ 08.2 Pneumococcal septicemia February 20 None March 20 Alaska Regional Hospital $26,0.50 $8,62.2 $0.00 /7/- /5/ /20/ /27/ 58.8 Acute respiratory failure 2 UW Medical Center $26,8.69 $75, $0.00 Guardian Flight Inc $6, $5,970.8 $0.00 2/5/- 2/2/ /2/- /8/ // /6/ Other sequelae of chronic liver disease // /8/ 58.8 Acute respiratory failure Alaska Regional Hospital $5,09.00 $28,9.65 $0.00 /2/- 2/5/ 2/27/ // 28. Antineoplastic chemotherapy induced pancytopenia (blood cell deficiency) 5 Providence Alaska Medical Center $9,67. $22, $0.00 /5/- /2/ // /20/ 58.8 Acute and chronic respiratory failure April 20 UW Medical Center $267,87.6 $59,77.92 $0.00 /2/- 2/27/ // /8/ 96.2 Mitral valve insufficiency and aortic valve stenosis 2 Month Average Amount Billed: $72, Month Average Amount Paid: $29, Includes claims with paid amounts $00,000 0

12 Plan Age Distribution Summary April 20 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 25 8 Total 8 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 May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- 2

14 Enrollment Activity by Plan - Non Medicare Plans May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- $000 Deductible $,500 Deductible $2,500 Deductible $5,000 Deductible $0,000 Deductible $5,000 Deductible $,000 Std Deductible

15 50 Enrollment Activity by Plan - Medicare Plans May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- Carveout Med Supp A Med Supp I Med Supp F

16 Enrollment Activity Month Start Adds Pended Adds* Terms Retro Terms** End Net Change May () Jun Jul (6) Aug () Sep () Oct () Nov (2) Dec Jan (79) Feb (9) Mar (7) Apr (2) 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// - /0/) 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 Apr % % % 5 2% % 5 Termination Reasons (data from 6// - /0/) Count Percent Apr- Retro Terms** Free look period 6 % - - Too costly 2% - - Deceased 22 % - - Lifetime Max 0% - - Medicare / Medicaid 92 % 2 Moved out of state 9 6% - - Unknown - Letter sent to request reason for termination 75 % 6 Non-payment 20 29% 7 Obtained other coverage 26 5% 7 - Total %

17 Plan Age Distribution - NEW ENROLLMENT April 20 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: REINSTATEMENTS: 2 (Not included in New Enrollment count) 6

18 Top Producers Agent Name Agency Location Commissioned Apps Ayme Cardwell Davis-Barry Insurance Ketchikan 5 Nancy Tietje Davis-Barry Insurance Ketchikan 2 7