November 24, Government of Bermuda Health Insurance Department Automation and Modernization Project

Transcription

1 November 24, 2011 Government of Bermuda Health Insurance Department Automation and Modernization Project

2 The Apollo Group: Healthcare Pedigree One of the largest global healthcare services organizations 25 years of experience, strong brand and commitment to quality healthcare Apollo is a family of 64,000 healthcare professionals Largest TPA network managing nearly 10 million lives Third Party Administration Apollo Health Street Health Education & e-learning 10 nursing, 3 hospital management, physiotherapy and much more Over 1,200 centers across the country Retail Pharmacies Clinical Research Focus on Phase 3 & Phase 4 trials: Working with leading pharmaceutical companies Over 50 centers focused on ambulatory care and wellness Primary Care Clinics Owned / Managed Hospitals 4 th largest global hospital. 45 hospitals with 9300 beds Health Insurance India s most innovative, pure-play health insurance company

3 ACHIEVING HEALTHCARE S TRUE RETURN Global Platform and Capabilities Global delivery centers provide significant advantages with seamless operations Provides for intra and inter city redundancies in global operations Conshohocken, PA Third-Party Large Claims Follow Up Self-Pay Collections Denial Management Bloomfield, NJ Charity Care and Eligibility FBO and EBO Services Self-Pay Collections New York, NY Account Management IT/IS Support Delhi, India Software Development and Upgrades Technical Support and Help Desk Services Los Angeles, CA Medi-Cal / Medicare Billing Medi-Cal / Medicare Collections On-Site FBO Process for Client Springfield, IL Medicaid Application Services/Eligibility Americus, GA Mail Room / Scanning Claims Re-Pricing & Adjudication Help Desk / Customer Support Provider Calls Sunrise, FL Bad-Debt Collections EMS Carrier Follow Up Client Relations & Appeals Boston, MA Third-Party Large Claims Follow Up Self-Pay Collections Denial Management 3 Government of Bermuda Chennai, India Opened facility in Aug Physician Revenue Cycle Payer Data Management Hyderabad, India (2 Offices) Eligibility Coding Billing / Credit Payment & Posting Third-Party Follow Up Data Entry Claims Re-Pricing & Adjudication Software Development Implementation Training Interfaces

4 Technology Bermuda Health Insurance Department Challenges Prior to Automation An AS400 application supported policy administration and billing for one customer segment only All the other work including claims adjudication was processed using paper and excel spreadsheets Lack of confidence in the integrity of the eligibility, claims, and billing data Inability to capture and analyze data related to claims utilization, premium and eligibility Process Lack of properly documented policies and procedures Undocumented business rules resulted in inaccurate and inconsistent application of claims adjudication People With no automation, staffing levels were not sufficient to support the volume of work resulting in backlogs and dissatisfied customers and providers

5 Technology Bermuda Health Insurance Department Automation Action Plan Select and Implement a state-of-the-art Health Plan Administration System System to enable automation and integration of claims adjudication, premium billing and enrollment System to enable reporting for measurement of all operational and strategic KPI s claims utilization, premiums, and enrollment System to enable electronic exchange of data between stakeholders hospital, physician, pharmacy, and finance Process Documentation of all Business Rules, Policies, Procedures and Workflows to ensure consistency and efficiency in all service areas Eliminate backlogs to improve customer service to members and providers People Partnership with healthcare BPO to deliver back office transactional services for non-customer facing functions

6 Bermuda Health Insurance Department Global Partnership Solution Retained customer service, finance, audit, marketing, and strategic planning Implemented the technology solution and performs back office administrative functions claims adjudication, enrollment processing, eligibility updates, premium and standard reporting Coordinated the development of policies and procedures working with Apollo Subject Matter Experts and HID and provided other project management support Provided the Health Plan Administration System (LuminX) through an ASP delivery model

7 System Selection and Implementation Selected state-of-the-art Benefit Administration Software based on analysis of functional requirements detailed in government-issued RFP --- LuminX System from Ebix. Chose ASP data model for increased data security, rigorous backup of data, a robust disaster recovery / business continuity strategy, reduced capital expenditures and reduced cost of hardware support and maintenance. Apollo professionals provided systems implementation, plan building and training support Refined functional requirements during assessment phase. Produced gap analysis and initial configuration and enhancement specifications. During implementation, developed cleansing and normalization strategy for data, transformed and then migrated data from previous systems and other external sources

8 LuminX Health Plan Administration System Over 10 million covered lives 120 clients: TPAs, carriers, health plans, and others

9 ASP Delivery Model

10 Automation of Claims Adjudication Logic and Premium Billing Configured claims adjudication parameters for automated processing based on legislated benefit packages, adjudication rules and funding mechanisms Adjudication configuration increased productivity and accuracy of claims processing Integration with eligibility and billing data enables more accurate adjudication based on premium status and eligibility dates Configured premium rate tables for individuals and employer groups for automated billing

11 Electronic Data Exchange with Key Stakeholders Implemented acceptance of electronic pharmacy claims Implemented acceptance of electronic hospital claims (837 format) Implementation in progress for electronic explanation of benefits (835 format) to providers who are submitting electronic claims Implementation in progress for acceptance of medical claims (837 format) from non-hospital providers Implemented electronic payments to providers Developed electronic eligibility updates to US provider network, dental administrator, hospital Developed automated data extracts to print vendor for high volume printing and mailing of billing statements and EOB s

12 Reporting and Web Portal Robust standard and ad-hoc operational reporting for claims, premium, and enrollment Cognos data warehouse for executive-level decision support and KPI tracking Standard and ad-hoc financial reporting Web portal for providers and policyholders to verify benefits and check claim status

13 Leveraging New Technology and Back Office Partner Apollo s Blended Shore Delivery Model allowed access to both US and India-based resources for subject matter expertise in health plan administration and operational management Cost-effective and high quality claims adjudication service from Apollo increased accuracy and reduced turn-around-times Backlogs eliminated during implementation and ramp up

14 Documentation of Business Rules and Workflows Documented all existing manual workflows Mapped out future state workflows affected by business process outsourcing and new technology Contributed best-practices and subject matter expertise to client s development of new policies and procedures

15 Business Strategy: Global Business Partnerships Strategic partnerships providing both the operating system and professional support Apollo s administrative support provided improved performance through a cost effective multi-shore delivery model Bermuda was able to focus on measuring performance and overall delivery improvements while business partners handled volumes Partnership approach provided subject matter experts from Apollo and EBIX along with project management support from IBM EBIX platform provided state-of-the-art capabilities in automation, processing, and reporting ASP delivery model provided robust Disaster Recovery capabilities while minimizing support costs Ability to leverage strategic partnerships provided flexibility in staffing support for implementation, backlog reduction, and on-going support

16 Key Tactical Outcomes of Automation Project Reduced claim payment turnaround times and accuracy of claims adjudication, improving relationships with providers, policyholders and other stakeholders Optimized back office operations resulting in more efficient use of existing resources Optimized electronic data exchange with key stakeholders improving efficiency of Bermuda s healthcare finance system New processes and systems enabled capture of data previously unavailable resulting in improved audit results and executive decision support Reduced claim costs by standardizing processes and using the available information to manage claims more effectively Allowed HID staff to focus more on customer service and strategic management of business