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Plans Need Efficiencies To Maintain Margin

Plans Need Efficiencies To Maintain Margin

With the advent of much stricter bidding rules in almost all lines of business, as well as the introduction of minimum medical loss ratios (MLRs), plans are struggling to maintain margins. The poorly financed Exchanges resulted in notorious losses for many plans in most states, hence the plan pullouts over the last few years. As it applies to the Medicaid line, state-hired actuaries generally peg a margin at a paltry two-percent (2%). However, depending on how good or bad “actuarially sound assumptions” are, sometimes the Medicaid line will report negative margins. While Medicare is the place to be, the rate realignment under the Affordable Care Act (ACA), and the race to gain membership by offering the best benefits possible has limited margins here, too.
So, what is a plan to do? Many plans have yet to truly assess efficiency in their organizations and make the kind of investments in technology that can be a game changer in the administrative cost areas. While plans think they are efficient, so much more can be done.

At MedHOK, our platform is based on the twin pillars of compliance (our mainstay) and efficiency. Indeed, the two very often go hand in hand for efficiency tends to beget compliance. MedHOK solutions focus in on automation of workflow, business rules and alerts whenever possible. Key improvements include:

  • Efficient intake of cases, including electronic intake whenever possible
  • Robust member history to reduce errors and provide unprecedented insight
  • Auto-population of case receive dates and countdown to the due date through dashboards, alerts, and other functionality
  • Automated workflow and monitoring throughout the case life
  • Automated correspondence generation, correspondence triggering (in most cases) and correspondence monitoring to ensure compliant and timely fulfillment
  • Barcoding and auto-generation of medical necessity outreach, appointment of representative, and waiver of liability requests
  • Real-time effectuation of approvals and tight integration with other fulfillment vendors (fax, letter and IVR) to ensure timely fulfillment
  • System auto-population of fields whenever possible
  • Out of the box universes to always be audit ready
  • Superior availability through a secure hosting infrastructure

Learn more at: www.medhok.com

How can plans drive efficiency in the areas of prior authorization, appeals, and grievances? Consider the following out of the MedHOK best practice playbook:

  • Use of both pharmacy and medical evidence-based decision trees configured in a technology system reduces training time, case timeframes and human error, as well as ensures consistency for compliance. It also reduces the use of higher cost clinical personnel time (pharmacists and medical directors) and reduces the filing of appeals.
  • Incorporate ePA standards set forth by the National Council for Prescription Drug Program (NCPDP) to drive huge efficiency gains. We notice that many plans quickly increase market adoption of the ePA solution. Various vendors such as SureScripts, CoverMyMeds and CenterX seamlessly integrate directly with electronic medical record systems (EMRs) and MedHOK to deliver eligibility checks, benefit and formulary checks, and evidence-based decision trees, which equate to no-touch pharmacy prior authorizations helping plans to reduce administrative costs and increase process efficiencies.
  • Drive adoption of electronic intake through provider portals. Driving providers to your portal for electronic submission substantially reduces the costly administrative intake processing step.
  • Adopt auto-authorization strategies in your core system and provider portal for both pharmacy and medical that are similar to what was outlined for ePA. To be consistent with regulatory requirements, plans can launch evidence-based logic and decision trees via portals and drive seamless case approvals. Even if cases do not meet auto-authorization requirements, at least you have avoided manual intake and can likely get submission of medical necessity documentation through a portal upload process.
  • Adopt more complex medical side auto-authorization approaches, including integrating with MCG’s and Change Healthcare’s auto-authorization tools. As with the various ePA vendors, MedHOK is integrating with both these entities to deliver a full-range of auto-authorization strategies.
  • Increasingly, we are seeing various entities seeking to replicate the pharmacy ePA process for medical. Various entities, including MCG, Change and clearinghouses are laying the foundation for EMR and other system submissions of electronic medical authorizations to plan systems like MedHOK. We are integrating with MCG, Change and clearinghouses to do just that.
  • Traditional OCR strategies are good ones. Although complex and time-consuming, they can convert remaining faxes, mail and email into electronic cases. A concerted effort touching all aspects of a health plan operations (including provider adoption of new templated forms) is essential. But it can be worth it.
  • At the same time, technology should soon allow plans reliably to use artificial intelligence (AI) and optical character recognition (OCR) as a replacement of traditional OCR form-driven processes. The AI/OCR component will allow reading of disparate forms and vehicles and the conversion of these into electronic submissions at high accuracy rates.

Even though ramping up efficiency is not easy, there are numerous best practices for your tool kit. So as not to get overwhelmed, I suggest that you start smart and small (do what you can accomplish quickly and reasonably) then build from there. In the end, many of our plans report efficiency gains of up to one-third (1/3) or more by employing many of these strategies.

Marc Ryan

Marc S. Ryan serves as MedHOK’s Chief Strategy and Compliance Officer. During his career, Marc has served a number of health plans in executive-level regulatory, compliance, business development, and operations roles. He has launched and operated plans with Medicare, Medicaid, Commercial and Exchange lines of business. Marc was the Secretary of Policy and Management and State Budget Director of Connecticut, where he oversaw all aspects of state budgeting and management. In this role, Marc created the state’s Medicaid and SCHIP managed care programs and oversaw its state employee and retiree health plans. He also created the state’s long-term care continuum program. Marc was nominated by then HHS Secretary Tommy Thompson to serve on a panel of state program experts to advise CMS on aspects of Medicare Part D implementation. He also was nominated by Florida’s Medicaid Secretary to serve on the state’s Medicaid Reform advisory panel.

Marc graduated cum laude from the Edmund A. Walsh School of Foreign Service at Georgetown University with a Bachelor of Science in Foreign Service. He received a Master of Public Administration, specializing in local government management and managed healthcare, from the University of New Haven. He was inducted into Sigma Beta Delta, a national honor society for business, management, and administration.

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