Transcript Document
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Copyright © 2014 TriZetto Corporation
Operational/Automation
Analysis
Samantha Goff – UMR Operations Manager
Susan Bostick – TriZetto Business Consultant
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UMR - Pursuit of Continuous Improvement
UMR initiated a cross functional work group focused
on improving auto adjudication
The team identifies opportunities for updates through:
Updates to business configurations,
Modifications to existing workflows and processes and/or
Solutions that require programming support.
The team evaluates auto adjudication at the directory
level and plan level.
The team identifies new opportunities; prioritizes
identified solutions based on business need and
projected impact; and monitors impact of implemented
solutions.
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Directory Level Auto Adjudication Review
Directory level review evaluates:
Overall auto adjudication rates by directory and benefit type
Utilization of claim comments and line comments
Auto adjudication based on specific codes (benefit code, procedure
category, diagnosis category, procedure code, etc.)
Recommendations received by team members
Directory level review results in:
Updates implemented through business configurations
Updates that require programming support to improve auto
adjudication
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Plan Level Auto Adjudication Review
Plan level review evaluates:
Volume of members with comment codes in EM/EDM
Auto adjudication based on benefit type and benefit code
Utilization of claim comments and line comments
Plan level review results in:
Updates to current benefit configuration we can implement with
business configurations without updates to the benefit design of the
plan
Provide recommendations for benefit design updates to consider
implementing in the future that would support increased auto
adjudication
Updates that require programming support to improve auto
adjudication
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Automation Review Request
The auto adjudication team recommended support
from TriZetto to complete an analysis and provide
recommendations
Feedback from the TriZetto perspective would help to:
Identify opportunities to improve current configurations
Review functionality available in future release to implement
Evaluate existing processes and workflows
Automation review included detailed analysis of a
sample of plans
Plans selected based on claim volume, current auto adjudication
rate, and specific benefits that are common or difficult to administer
UMR provided plan benefit information, code configuration
information and auto adjudication baseline amounts for the plans
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TriZetto Review and
Preparation for
Onsite Meetings
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TriZetto Review & Preparation
Primary goal was to identify ways to gain efficiencies
through system setup changes, workflow process
changes and automation improvements
Comprehensive review of client identified plans
Focus on plan structure & standardization
Build accuracy and proper use of system functionality
Comprehensive review of CBX table for specified plans
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Structure
Features utilized (COI & Copay override, Seq messaging etc)
Plan exception usage
Was automation maximized
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TriZetto Review & Preparation
Claim Workflow system setup
Evaluated how system responses were established in claim
workflow programs (CBSX, CECM, CEPM)
How system was established
Up-to-date on code loads (Diagnosis/CPT/HCPCS)
Code categorization – extent of breakdown
Modifiers established (GMP & MMD-CM)
Calculation parameters
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Onsite Collaboration
Session with TriZetto
and UMR teams
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Onsite Automation Review
Susan traveled to the UMR office in Onalaska,
Wisconsin to facilitate work sessions for a week with
representatives from the UMR teams: Claim
operations, plan coding, Eligibility, Repricing, IT
During the work sessions, we reviewed:
Current configuration set-up for the plans provided
Reviewed business work flows and business rules that contribute to
our current configuration design
The sessions provided an opportunity to exchange
feedback, ask questions and collaborate on alternative
solutions to consider.
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On- Site Review
Plan Builders – discuss workflow
New business versus plan changes
Ways to streamline plan building
Discussed perceived automation inhibitors
Review dental plan setup to minimize work effort
Discussed analysis findings
CBX workflow & modification recommendations
Use of new/existing functionality
How to monitor automation improvements
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CECM- field 14-display routing errors only
CECM- field15- update workflow audit trail
Assess Claim Exception Listing (CER)
ClaimWorkflow Audit Inquiry (CBAUDTI), monitor 1st pass
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TriZetto
Recommendations
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TriZetto Recommendations
After the sessions, Susan prepared a report that
included her recommendations and observations. She
acknowledged the areas where the current
configuration and workflow were optimal to support
our current business needs with no improvements
identified. She presented recommendations for
updates to consider to current configurations to
support increased flexibility and auto adjudication. In
addition, she presented recommendations for updates
to consider to current workflows to increase
productivity and efficiency.
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After the Onsite
Collaboration
Session
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Automation Review Action Plan
UMR created an action plan based on the automation
review results
Feedback from work sessions incorporated into plan
Recommendations TriZetto automation report added to plan
Action plan captured recommendations to implement
immediately, updates to implement in the future, and
track our progress with implementation of changes
that were a result of the analysis.
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TriZetto Recommendations
Updates implemented impact:
Plan testing process updated to minimize impacted claims and
support increased auto adjudication
Implemented updates to CEPM, GADP, CBX records to support
increased auto adjudication
Enhance code categorization in MM to support increased flexibility
and auto adjudication
Updates identified for implementation in the future:
Refine claim processing workflow to further leverage mailbox
routing and use of the ‘g’ option
Evaluate use of plan exception codes to identify root cause,
decisions required, and solutions to eliminate the need to manually
process the claims
Review system capabilities after upgrade (PMCR, DVT, etc.)
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Keep appraised QicLink changes
Point person(s) to stay current on system changes to
QicLink
Customer Exchange – disseminate the information
Review upgrade release information
Review PAR listings
How-To-Section
Did you know videos
ICD-10 Corner
QicLink e2 Corner
Exception processing-How to & what not to do
Take advantage of annual conference presentations
Minicasts and Webinars
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Workshop Survey
We would like to extend you an opportunity
to provide candid feedback.
During the workshop you should have received an e-mail
notification for you to take an on-line survey.
If you could take a few minutes to complete at this time ,
we would greatly value your feedback. For your convenience,
the survey will be available throughout the remainder of the conference
should you not be able to complete immediately.
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Thank You!
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