The Compliance Advantage in Medicare Advantage A journey from the brink to the fore front

Jeremy Dressen, Vice President, Medicare Operations

•

Medicare Advantage

Commercial

• Founded in 2007

• Serving over 23,000 MA members

• 9% market share of Seattle/Tacoma

• RiverLink Health & HeartlandPlains Health founded in 2015

• QCA founded in 2016

• Serving over 4300 combined members

• Founded in 1994 • Serving over 137,000 members • Products Include:

• Employer Sponsored • Exchange • Individual • ASO • Med Sup

69% MA member growth since CHI acquisition

Catholic Health Initiatives

• Founded in 1996

• One of the nation’s largest non-profit hospital systems, CHI operates in 17 states & comprises over 100 hospitals, 11 clinically-integrated networks, and a diverse network of facilities/services that span the care continuum.

• More than $15.9B in revenue and $1.1 billion in financial assistance FY2016

90% Commercial member growth since CHI acquisition

Why focus on Appeals & Grievances?

• High Risk: CMS Program Audit

• High Reward: Medicare Star Ratings

U.S. Government suspends enrollment in Cigna Medicare Advantage, drug plans. - Reuters Health News, Jan 22, 2016

“The U.S. government has suspended new enrollment in

Cigna Corp’s Medicare Advantage health insurance and

prescription drug plans, saying Cigna had ‘widespread and

systemic failures’ that prevented patients from accessing

medical services.

The government said Cigna did not handle complaints and

grievances properly from patients who had been denied

coverage for health benefits or drugs…These deficiencies

posed ‘a serious threat to the health and safety of Medicare

beneficiaries’ and followed years of noncompliance.’”

http://www.reuters.com/article/us-cigna-medicare/u-s-government-suspends-

enrollment-in-cigna-medicare-advantage-drug-plans-idUSKCN0V01LV

Our Business Imperative

2014 – Measurement Year 2015 – Reporting Year 2016 – Year 2017 – Bonus Year

Medicare S TAR Performance

S oundPath HealthWt.

MY 2014

Actual

Appeals Auto–Forward 1.5 1

Appeals Upheld 1.5 1

Plan Makes Timely Decisions about Appeals 1.5 2

Reviewing Appeals Decisions 1.5 3

Complaints about the Health Plan 1.5 4

Members Choosing to Leave the Plan 1.5 4

Beneficiary Access and Performance Problems 1.5 3

CAHPS Customer S ervice 1.5 3

Improv. Health Plan Quality Improvement 5 1

IRE

CMS

Member Quicker response time and case completions

Case status information readily available

Provider Quicker response time and case completions

Case status information readily available

Simplified experience

Staff Organized workflows and queues

No manual tracking

Seamless letter generation

Quick access to necessary documentation

Leadership Consolidated view of case status and SLA performance

Accurate, timely CMS reporting and audit readiness

Workload management

Stable, reliable environment

Initial Goals for A&G / Pega

Agile Development Approach

• Project team formed; strong collaboration among SMEs, IT, vendors

• Executive level ownership and oversight

• Well laid plans; but commitment to flexibility

• Ticketing system, scrums utilized to support Agile development process

• 27 product releases since Sept. 2015

• Model office approach for future projects

Your Logo Here

QualChoice Health IT – Support and Development

QualChoice Health Automated Workflow

VPN – Secure Connection

Pega Cloud

Pega Healthcare

Industry Foundation

QualChoice Health

Trizetto QNXT Claims Management – Member lookup

Fax Server - Authorizations

Microsoft Exchange Email

Active Directory – User Authentication

Pega Cloud Operations

Appeals & Grievances Application

Utilization Management

Tracker Application

Pega Product Technical Support

Support and Agile Development Partner - Capgemini

QualChoice/Pega Logical Architecture

Multiple avenues for intake; 19 Searchable / Reportable Fields

Level of Appeal

Case ID

Case Type

Claim ID

Authorization Number

Member ID

Member Name

Provider Type

Provider ID

Provider Name

Ancillary Name

Facility Name

Received Date/Range

Case ID (hyperlink)

Level of Appeal

Health Plan Name

Type of Appeal/Grievance

Priority

Status

End users include:

• A&G Staff

• Customer Service

• Nurse Care Managers

• Pharmacists

• Administrative Staff

• Sales

• Claims

• Medical Directors

Intuitive Layout for Diverse Staff Needs

Complex Business Rules Made Simple

Real Time Work Baskets, Status and Dashboard

Integrated Case Documentation & Letter Generation

Practically Magic Reporting

RESULTS

Successfully addressed all CMS compliance areas

Real-time information for members, providers on case status

Reporting cycle time down >50%

FTE costs reduced by >33%

Improvements in employee retention, morale

Agile process - Pega successfully deployed to prior authorization

Major STARs improvements

Results

*Based on CMS Plan Preview Data

**Based on internal QualChoice monitoring and trending against published CMS cut-points

***N=13; N/A at <10

Medicare S TAR Performance

S oundPath HealthWt.

MY 2014

Actual

MY 2015

Actual

MY 2016

Actual*

MY 2017

Forecast**

Appeals Auto–Forward 1.5 1 5 5 5

Appeals Upheld 1.5 1 N/A 2*** 5 or N/A

Plan Makes Timely Decisions about Appeals 1.5 2 3 4 5

Reviewing Appeals Decisions 1.5 3 3 5 5

Complaints about the Health Plan 1.5 4 5 5 5

Members Choosing to Leave the Plan 1.5 4 5 3 5

Beneficiary Access and Performance Problems 1.5 3 2 5 S unset

CAHPS Customer S ervice 1.5 3 3 4 4

Improv. Health Plan Quality Improvement 5 1 3 5 TBD

IRE

CMS

Closing Thoughts

• Don’t forget the human equation

• [Thought] process reengineering critical to maximizing PEGA capability

• Agile development allows rapid iteration & continuous process improvement with end users

• Test, test, test

• And most importantly…