improving the provider experience administrative simplification

Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group.Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group.

Improving the Provider Experience Administrative Simplification – Collaborative Approach Delivers Results

WCBF Lean, Six Sigma and Business Improvement in Healthcare SummitMay 12-13 2010, New Orleans

Deborah Smith-Fedon

Director, Process Performance Program

Provider Service Quality, UnitedHealthcare

Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group.

Process Performance ProgramMutual Benefits

WHAT…..The Process Performance Program leverages a provider-focused project model that expands upon a proven Six Sigma-based process improvement methodology.

WHY….To improve 1st Pass Claim Payment Accuracy, Optimize Current Contract Performance, and Improve Hospital and Physician group Relationships.

VALUE….The program recognizes that the combined processes produce discrepancies that are not recognizable when looking at the hospital’s, physician’s and UHC’s systems independently – a partnership approach enables the highest capability of identification.

HOW …DMAIC methodology engaged to deliver fact-based results; improve processesin a structured project format.


Observation

Individual Value

19017115213311495765738191

0.9

0.8

0.7

0.6

0.5

0.4

0.3

0.2

0.1

0.0

_X=0.0457

UCL=0.1149

LB=0

Initial = 0.2462 Final = 0.0457

11

1

11

1

2007 - 2009 Discrepancy Rate Improvement

Process Performance ProgramResults

PROVEN SUCCESSES

• 97 projects• Overall shift in the Mean Discrepancy Rate from 24.6% to 4.57%• Average 81% improvement in discrepancy reduction

A discrepancy is any time the UHC reimbursement does not match the Hospital or Medical Groups’ expectation.


Comparison of Initial & Final Discrepancy Rate

Paired T for Final Proportion - Initial ProportionN Mean StDev SE Mean

Final Prop 97 0.045691 0.026871 0.002728Initial Prop 97 0.246237 0.177578 0.018030Difference 97 -0.200546 0.173079 0.01757395% CI for mean difference: (-0.235429, -0.165663)T-Test of mean difference = 0 (vs not = 0): T-Value = -11.41 P-Value = 0.000

Q: Has there been a significant decrease in the discrepancy rate for the 97 projects?

A: Yes – the use of the Process Performance Program has been successful at reducing the discrepancy rate from a mean of 24.6% to 4.6%.

Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group.Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group.

Process Performance ProgramProgram Overview

Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group.6

Six Sigma Disciplines

Proc

ess

Stan

dard

izat

ion

Process Design

Process Improvement

DMAICDefine–Measure–Analyze–Improve–Control

Lean

Prin

cipl

esD

MA

DV

Define–M

easure–Analyze–D

esign-Validate


Project Model by DMAIC Phase

Define ControlImproveAnalyzeMeasure

Identify candidates

Executive Introduction

Scope Project

Complete Charter

Random Sample

UHC analyzes

data

Provider analyzes

data

Compile Research

Baseline Defect Rate

Collaborative Defect

Review & Root Cause

Analysis

Stratification & Statistical

Analysis

Define/ Measure/ Analyze Tollgate

Improvement Plan

Implemented

Improve Tollgate

Claims Rollout time: 6-8 weeks

Final Defect Rate

Control Plan & Scorecard

Control Tollgate

Random Sample

UHC analyzes

data

Provider analyzes

data

Compile Research

• A discrepancy is any time the UHC reimbursement does not match the

Hospital or Medical Groups’expectations


The Process Performance Program Project Life Cycle

Project Cycle Time is between 6 – 8 months.

Resource allocation intense during Planning Phase and 3 Day onsite meeting


Process Performance ModelRoles & Responsibilities

UHC Resources

• Black Belt(s): Project lead/HP3 staff.

• Master Black Belt: Assists Black Belt on an as needed basis with technical expertise.

• Project Sponsor/Business Champion: Executive on point to guide team as needed

• Hands-On Champion: Executive on point to guide team as needed.

• Process Owner: Expert in knowing contract intent and translation, accountable for on-going provider relationship, aware of improvement opportunities/issues.

• Data Miners: Claim research expert/HP3 staff.

• Subject Matter Experts : Engaged as appropriate;

Provider Resources

• Black Belt(s): Project lead/Hospital Six Sigma program staff.

• Master Black Belt: Hospital Six Sigma program staff.

• Project Sponsor/Business Champion : Typically hospital CFO or COO .

• Hands-On Champion: Typically VP of Managed Care/Patient Account Services.

• Process Owner: Typically a Director or Manager of Hospital/Health System Billing.

• Billing Coordinators : Billing research expert .

• Subject Matter Experts: As appropriate; technology managers, notification staff, etc.

Opt

iona

l


Process Performance Program Kick Off Meeting

The project kick-off meeting is the formal start of the project and should be attended by all project spons ors and stakeholders

Key Points to be Covered:

• Team Members & Roles• Project timeline & Tools• Meeting schedule for RDM Session

Planning• Data Discussion

Champion/Sponsor(s):

Process Owner(s):

Problem Statement: ABC Health System averaged 3,106 (combines UNET, COSMOS, & FACETS) claims submitted per month to UnitedHealthcare from July 2008 through June 2009. A deep dive analysis of 500 ABC’s claims with October 2009 dates of service found that xx.x %of the claims had discrepancies between the payment that ABC expected and the amount allowed / paid by UHC.

Critical to Quality (CTQ): Matching ABC’s contractual expected amount and posted payments to UHC’s allowed amount for each claim.Defect: Discrepancies between ABC’s contractual expected amount and posted payment, and UHC’s allowed amount for each claim (includes UHC and patient’s liability).

Lead Black Belt: Master Black Belt: Team Members: See Next Slide

Process Name: ABC/UHC–Claim Adjudication and Payment; ABC –

Bill Generation, Submission & Reconciliation

Customer Impact: Improved claims process will decrease rework for

ABC and UHC. Customer satisfaction will improve with less claim

discrepancies. Improved relationship with ABC

Project Scope/BoundariesIn-Scope: Commercial physician services claims covered under the contract between ABC and UHC and billed on a HCFA 1500.

Out-of-Scope: Medicare & Medicaid products, along with and all other services not covered under the contract between ABC and UHC

Start / Stop: Patient service is scheduled / Account for service is zero-balanced by ABC

Goal Statement: Reduce ABC /UHC payment discrepancies from xx.x % to ?5%by May 31, 2010

PhaseEstimates

5/31/20105/1/2010Control

4/30/20102/16/2010Improve

3/19/201012/15/2009Analyze

3/19/201012/15/2009Measure

2/18/201012/15/2009Define

Completion DateStart Date

Lifecycle Phase

5/31/20105/1/2010Control

4/30/20102/16/2010Improve

3/19/201012/15/2009Analyze

3/19/201012/15/2009Measure

2/18/201012/15/2009Define

Completion DateStart Date

Lifecycle Phase

=5%TBDDiscrepant Claims

TargetCurrentProcess Metrics=5%TBDDiscrepant Claims

TargetCurrentProcess Metrics

The project charter & process maps are often introduced to the team at this point


Red = Location of root causes

Sample Process Map & Root Cause Locations


Project Data Requirements

• Discrepancy Definition: A discrepancy is any time the UHC reimbursement does not match the Hospital or Medical Groups’ expectations.

• Data Population = 1-3 months of service dates (depending on monthly volume)

• 300-500 random sample of claims extracted from population

• A MSA tool is populated using random sample data. This tool is used by BOTH organizations to identify discrepancies within the sample prior to the onsite RDM.


Percent

Count 60

Percent 45.8 22.6 8.3 7.3 4.6 3.2 2.2 1.9

693

4.0

Cum % 45.8 68.4 76.7 84.1 88.7 91.9 94.1 96.0

341

100.0

126 111 70 49 33 29

Other

Detail H

Detail G

Detail F

Detail E

Detail D

Detail C

Detail B

Detail A

1500

1200

900

600

300

0

100

80

60

40

20

0

Detailed Root Cause for Process A

Discovering the Root Cause

Drill down analysis of discrepancies is performed through the use of “5-Why’s”methodology to get to actionable root causes

Count

Percent

Count 237 164 163 226Percent 23.4 12.2 12.0 11.5 9.7

15129.7 5.6 3.8 3.7 2.5 2.5 3.5

Cum % 23.4 35.6

789

47.6 59.0 68.7 78.4 84.0 87.8 91.4 94.0 96.5 100.0

774 741 629 627 360 244

Other

Proce

ss I

Proce

ss H

Proce

ss G

Proce

ss F

Syste

m B

Proce

ss E

Proce

ss D

Syste

m A

Proce

ss C

Proce

ss B

Proce

ss A

7000

6000

5000

4000

3000

2000

1000

0

100

80

60

40

20

0

Discrepancies by Root Cause


Onsite Rapid Decision Making Session


Improve and Control PhasesRe-Measure Analysis

If..

Goal has been met, Then...• Finalize scorecard and control plan• Close out project

Goal has NOT been met, Then...• Review discrepancies for root cause• Check for new solutions• Implement new solutions• Re-measure to check for improvements(Repeat improve & control phases)

Statistical tests are performed to determine validity of project results.

Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group.16

Control Plan and Scorecard

Control PlanThe Control Plan ensures that performance shifts from either entity are detected early

ScorecardThe scorecard indicates when engaging the response plan is appropriate

As of DateCombined Scorecard

Explanation of Variances and Control Plan

Discrepancy Type

0

5

10

15

20

25

30

Type

ATy

pe B

Type

CTy

pe D

Type

ETy

pe F

Type

GTy

pe H

Type

ITy

pe J

Type

KTy

pe L

Type

MTy

pe N

Type

OTy

pe P

Type

QO

ther

Num

ber

0%10%20%30%40%50%60%70%80%90%100%

Cum

ulat

ive

%

Discrepancy Type Trend

0

5

10

15

20

25

30

01/10 02/10 03/10 04/10 05/10 06/10 07/10 08/10 09/10 10/10 11/10 12/10

Discrepancy Rates

0%

2%

4%

6%

8%

10%

01/1

0

02/1

0

03/1

0

04/1

0

05/1

0

06/1

0

07/1

0

08/1

0

09/1

0

10/1

0

11/1

0

12/1

0

Percent USL

Measurement Spec Limits Data Source FrequencyResponsible Party Dala Collection Plan Response Plan

Reference Docs

Discrepancy Rate X%

Discrepancy Report by cause code Monthly Owner A

Run standard report monthly; submit data by 15th working day.

Hold inter-company meeting to review descrepency data including type and trend. Develop related action plan to address specific causes. Scorecard

Discrepancy A X%Monthly provider scorecard Monthly Owner A & B

Run monthly provider scorecard. Submit data by 15th working day.

Complete assessment of drivers of increased discrepancy rate. If special cause, ensure resolution of cause. If trend; assess contract terms for provisions resulting in manual adjudication. Work with provider to resolve. Scorecard

Control Plan

Process: Provider Payment Match Process Owners: Owner A and Owner BReview Process and Frequency: Monthly Scorecard Inter-Company review if discrepancies exceed xx%

Previous State: Provider and UHC DMAIC project determined through a data sample that there was a xx% discrepancy rate as defined as actual payments versus expected payments.

Key solutions were developed and piloted to correct the problems 1) Solution A2) Solution B3) Solution C

To ensure that these solutions are finalized and remain intact to prevent return to the previous state, control measures and tools have been developed to assist process owners.

Process Control requires regular monitoring of these measures through data collection and analysis. The suggested response plan is included but the Process Owners may add to these responses. Their critical function is to take action when measures indicate operational reporting is getting out of control. If there are any questions about this plan, please contact the Process Performance BB.


Collaboration is Imperative

A combined process…

produces discrepancies that are not recognizable when looking at the Hospital or Medical Group and payer systems independently

A collaborative approach…

enables the highest capability of discrepancy identification

A common goal…

to improve administrative simplification for both organizations by improving the collective and respective processes that contribute to 1st pass claims payment accuracy


This is Just the Beginning . . .

improving the provider experience administrative simplification

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