Monthly Operations Report. January 2014

Transcription

1 Monthly Operations Report Monthly Operations Report January 2014

2 Pre-existing Condition Insurance Plan - Washington State (PCIP-WA) Levels of Service Contractual Levels of Service Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Enrollment Standards day Clean Application Process 100% 100% 100% 100% 100% 100% day ID Card Issuance 100% 100% 100% 100% 100% 100% 3. Accuracy 99% 100% 100% 100% 100% 100% Billing Standards day Paid-to Status Update 100% 100% 100% 100% 100% 100% 5. Accuracy 99% 100% 100% 100% 100% 100% Claims Standards % Notification 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% day Clean Claim Process 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 8. Clerical Accuracy 98% 100% 100% 100% 100% 100% 100% 100% 100% 99.7% 100% 100% 99.7% 9. Financial Accuracy 99% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 10. Overall Processing Accuracy 97% 100% 98.9% 100% 100% 100% 100% 100% 100% 97.0% 100% 100% 92.3% Customer Service Standards Sec. Speed of Answer 60 sec % Abandonment Rate 5% 2% 2% 1% 2% 1% 2% 2% 1% 1% 3% 3% 0% 13. Accuracy 95% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 14. Premium Refunds 99% 100% 100% 100% 100% 100% 15. Updates posted w/in 48 hours 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 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 2 - 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 4-100% scoring of (25) member audit of 14-calendar days or less from premium receipt to update of eligibility file paid-to-status. Standard 5-99% scoring of (25) member audit of accuracy for posting of correct payment, implementation of rate changes and premium account reconciliations during the reporting month. Standard 6-100% notification for all claims not paid within 10-business days during the reporting month. Standard 7-100% 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 12-5% or less call abandonment rate. Standard 13-95% or greater accuracy based on a 2% 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 2% enrollee audit during reporting month. Standard % responsible for posting web site updates within 48 hours of receipt. 1

3 4,000 Pre-existing Condition Insurance Plan - Washington State (PCIP-WA) Claims Received Average Claims Received = 1,728 3,961 3,500 3,403 3,540 3,000 3,032 3,125 2,500 2,000 1,964 1,500 1, Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 2

4 Pre-existing Condition Insurance Plan - Washington State (PCIP-WA) Service Code Analysis* For the Month of January 2014 Submitted PPO or Other Deductible Coinsurance Total Claim Code Description Charge Discount Ineligible Amounts Amounts Paid Lines ANCILLARY CHARGES $ 23, $ (1,755.72) $ - $ $ (194.59) $ 25, AMBULANCE $ 1, $ $ 6.38 $ - $ $ ANESTHESIA $ 1, $ (227.28) $ - $ $ $ 1, ACUPUNCTURE $ $ - $ $ - $ $ CHIROPRACTIC $ $ $ - $ - $ - $ DIAGNOSTIC TESTING $ 5, $ $ $ $ (173.64) $ 4, EQUIPMENT $ 16, $ 2, $ $ - $ 1, $ 12, EMERGENCY ROOM $ (50.74) $ (161.91) $ - $ - $ (250.93) $ INJECTIONS $ $ $ - $ - $ $ (331.07) 5 MISC CHARGES $ 3, $ $ - $ - $ $ 2, M/N OUTPATIENT $ $ - $ - $ - $ - $ OCCUPATIONAL THERAPY $ 10, $ $ - $ - $ - $ 10, OFFICE VISIT $ $ $ - $ - $ $ PHYSICAL THERAPY $ 11, $ $ $ - $ $ 11, SURGERY $ 9, $ 1, $ - $ $ 1, $ 6, SEMI-PRIVATE ROOM $ 50, $ $ - $ - $ 4, $ 45, SPEECH THERAPY $ 1, $ - $ - $ - $ - $ 1, TOTALS $ 137, $ 2, $ $ 1, $ 7, $ 124, *Represents claims adjudicated in the month. May not tie to the financials depending on the timing of voids and adjustments. 3

5 Washington State Health Insurance Pool (PCIP-WA) High Dollar Paid Claims Report Month / Year Case Provider Total Billed Total Paid Date of Service Date Rcvd Date Paid Primary Diagnosis February U W Medical Center $91, $91, /3/13-1/11/13 1/22/13 2/19/ Aortic valve disorders 2 Yakima Valley Memorial Hospital $113, $88, /18/13 2/1/13 2/15/13 V58.11 Encounter for antineoplastic chemotherapy 3 Yakima Valley Memorial Hospital $113, $88, /27/12 1/11/13 2/15/13 V58.11 Encounter for antineoplastic chemotherapy 4 Harrison Medical Center $71, $63, /26/12 1/2/13 2/19/ Other late amputation stump complication nec 5 Seattle Cancer Care Alliance $65, $56, /27/12 1/15/13 2/13/ Acute lymphoid leukemia w/o achieved remission March Harborview Medical Center Phys $166, $114, /18/12-10/2/12 1/31/13 3/14/ Cervical spondylosis with myelopathy 2 Swedish Medical Center $178, $77, /3/12 2/1/13 3/14/13 V58.11 Encounter for antineoplastic chemotherapy 3 Swedish Cherry Hill $96, $64, /17/13-1/21/13 2/12/13 3/4/ Disorders of meninges not elsewhere classified 4 Valley Medical Center $92, $54, /5/13-1/17/13 2/5/13 3/4/ Cervical spondylosis without myelopathy 5 Northwest Hospital Acute $107, $51, /12/13-2/19/13 3/7/13 3/20/ Diverticulitis of colon April U W Medical Center $344, $299, /27/13-2/20/13 3/8/13 4/30/ High grade myelodysplastic syndrome lesions 2 Providence Everett Med Center $119, $99, /28/13-3/3/13 4/29/13 4/30/ Mitral valve disorders 3 U W Medical Center $137, $60, /7/13-4/8/13 4/17/13 4/26/13 V57.89 Other specified rehabilitation procedure other 4 Peacehealth St Joseph $62, $60, /1/12 3/29/13 4/17/13 V58.0 Radiotherapy 5 Kadlec Medical Center $70, $59, /18/13-3/27/13 4/3/13 4/17/13 V30.01 Single liveborn hospital deliv by c-section May UW Medical Center $151, $131, /25/12-12/31/12 5/24/13 5/27/ Acute lymphoid leukemia w/o achieved remission 2 Northern ID Advanced Care $170, $119, /12/13-4/5/13 4/24/13 5/9/ Intracranial abscess 3 Tacoma General Allenmore $146, $85, /3/13-4/5/13 4/16/13 5/9/ Malignant neoplasm central portion female breast 4 Swedish Medical Center $149, $77, /5/12-12/17/12 4/24/13 5/8/ Rgn enteritis small intestine w/lg intestine 5 Tacoma General Allenmore $106, $76, /13/13-3/27/13 4/5/13 5/3/13 V30.01 Single liveborn hospital deliv by c-section 6 Harrison Medical Center $82, $71, /28/13-4/30/13 5/8/13 5/27/ Acut myocard infarct oth ant wall init epis care 7 Oregon Health & Science $87, $66, /15/13-3/29/13 4/19/13 5/9/ Acute myeloid leukemia in relapse 8 Skagit Valley Hospital $67, $55, /7/13 4/17/13 5/9/13 V58.0 Radiotherapy 9 Swedish Medical Center $99, $54, /28/13 4/6/13 5/2/13 V58.11 Encounter for antineoplastic chemotherapy 10 St Mary Medical Center $65, $51, /12/13 4/10/13 5/2/13 V58.11 Encounter for antineoplastic chemotherapy June Overlake Hospital Medical Ctr $211, $137, /12/13-4/21/13 5/1/13 6/3/ Unspecified ulcerative colitis 2 Swedish Cherry Hill $166, $100, /15/13-4/19/13 5/1/13 6/6/ Coronary atherosclerosis native coronary artery 3 Swedish Cherry Hill $115, $69, /20/13 6/6/13 6/27/ Atherosclero native art extremities w/rest pain 4

6 Washington State Health Insurance Pool (PCIP-WA) High Dollar Paid Claims Report Month / Year Case Provider Total Billed Total Paid Date of Service Date Rcvd Date Paid Primary Diagnosis 4 Swedish Cherry Hill $151, $66, /2/13 5/23/13 6/13/ Atherosclero native art extremities w/rest pain 5 Seattle Childrens Hospital $71, $63, /28/12-12/30/12 6/11/13 6/13/ Stricture or kinking of ureter 6 SW WA Med Ctr - Patient Accts $100, $53, /29/13-5/4/13 5/14/13 6/13/ Coronary atherosclerosis native coronary artery 7 St Joseph Hospital $55, $53, /8/13 6/7/13 6/18/13 V58.11 Encounter for antineoplastic chemotherapy 8 Virginia Mason Medical Center $58, $52, /20/13-4/29/13 5/6/13 6/6/ Unspecified septicemia July Central Washington Hospital $61, $56, /23/13-4/24/13 6/13/13 7/1/ Loc osteoarthros not spec prim/sec pelv rgn&thi 2 Walgreens Inf & Resp Srv $80, $55, /30/13 7/10/13 7/22/ Other deficiencies of circulating enzymes August Central Washington Home Infus $85, $79, /25/13-2/27/13 8/7/13 8/28/ Loc osteoarthros not spec prim/sec lower leg 2 Providence St Vincent Med Ctr $89, $76, /11/13-4/18/13 8/1/13 8/2/ Coronary atherosclerosis native coronary artery 3 Overlake Hospital Medical Ctr $88, $61, /25/13-3/26/13 7/30/13 8/21/ Acute myocard infarct unspec site init epis care September Western Regional Med Ctr $156, $142, /8/13-4/13/13 8/23/13 9/11/ Malignant neoplasm of cecum 2 Providence Sacred Heart $74, $66, /1/13-2/12/13 9/19/13 9/20/ Unspecified septicemia October Providence Mount Carmel Hosp $90, $86, /3/12-4/18/12 10/24/13 10/28/ Sepsis 2 U W Medical Center $76, $76, /26/13-6/30/13 8/20/13 10/1/ Coronary atherosclerosis native coronary artery 3 Swedish Medical Center $155, $74, /15/13 10/9/13 10/18/ Unspecified anemia November Central Washington $64, $59, /29/13-5/8/13 11/7/13 11/26/ Embolism and thrombosis of iliac artery December 2013 None January St Lukes Rehabilitation $104, $99, /15/13-3/20/13 1/9/14 1/10/14 V57.89 Rehabilitation proc nec 12 Month Average 12 Month Average Amount Billed: $418, Amount Paid: $304, Includes claims with paid amounts $100,000 through March 2011 and $50,000 from April 2011 on. 5