Responsibility (DOFR)
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1 Administrative Simplification: Coded Division of Financial Responsibility (DOFR) Healthcare Financial Management Association DOFR Webinar 11:30 to 12:30 p.m. November 15, 2011
2 Agenda Introduction to IHA s Administrative Simplification initiative and the DOFR project Advantages of Standardized Coded DOFR DOFR Workgroup Process DOFR Product Demo Guidelines Coding by Service Implementation and Maintenance Public Comment period
3 Administrative Simplification for Capitation Arrangements IHA is a statewide non profit with equal representation of health plans, physician i groups, and hospitals IHA role: program administration, demonstration projects, neutral convener and facilitator In 2010, IHA launched an Admin Simplification initiative and tested the feasibility of an all payer py portal Stakeholders identified three priorities: 1. Standardized, coded DOFR 2. Standardized eligibility format 3. Standardized benefit information 3
4 What is a DOFR? Division of Financial Responsibility (DOFR) Agreement exhibit used by health plans and providers to identify payment obligations under contract. A grid of service categories provided d by either the health plan, physician organization or hospital. Each service category will designate a financially responsible entity. 4
5 Current State Financial responsibility is not sufficiently defined Non standard dformats across plans Insufficient service descriptions Partial or no coding Unnecessary costs and frustration on behalf of billing departments and consumers About 5% of hospital denials are related to DOFR Physicians time on payer interaction and admin Claims ping pong and misdirection Balance billing issues AffordableCare Act s MLR requirements 5
6 DOFR Project Goal To develop and implement a standardized, coded DOFR framework for Commercial HMO/POS and Medicare Advantage populations 6
7 DOFR Advantages Useful tool for provider contracting, financial management, and claims administration of capitation/risk arrangements Reduces or potentially eliminates gray areas in defining which party has risk for a service Facilitates DOFR financial analysis, allowing parties to use identical codes to value service categories Facilitates incorporation of new codes, particularly if the new codes are clearly defined within a service category Enables similar, if not identical, DOFR system configuration by contracted parties, making the contractual relationship more efficient 7
8 DOFR Advantages Hospitals Can be used to direct claims to the appropriate entity When claims payment py is disputed, the DOFR can be used as a point of reference and can potentially reduce Provider Dispute Resolution volume Health plans ability to load a coded DOFR into their systems will reduce claims processing errors and reduce days in AR 8
9 DOFR Workgroup Participants Plans: Elly Menegus (Aetna) Cecil Nyein (Anthem/ Blue Cross) Nicole Brown (Anthem/ Blue Cross) Edie Parker (Blue Shield) David Lankford (Blue Shield) Kenny Deng (Blue Shield) Ellen Fagan (CIGNA) Margo Carroll (Health Net) Brian Jeffrey (United) Jennifer Helbock (United) Valerie Morse (United) Jennifer Hastie (United) Susan Galzerano (United) Hospitals: Carol Wanke (Sharp Healthcare) Ramona Saragosa (Sharp Healthcare) Hospitals, cont d: Linda Barney (Sharp Healthcare) Physician Organizations: Deb Henning (Brown & Toland) Janet von Freyman (Brown & Toland) Bruce Young (Cedars Sinai) i) Elizabeth Campbell (Cedars Sinai) Steve Linesch (MCS/GEMCare) Other: Dave Schinderle (US Bank/HFMA Southern CA Chapter Member) Greg Labow (Receivable Optimization Inc./HFMA /HFMASouthern CA Chapter Member) Nancy Hazlewood (Hazlewood Consulting, Inc.) Tom Williams (IHA) Janet Marcus (Sinaiko Consulting) 9
10 DOFR Workgroup Process Workgroup met weekly between February and July 2011 to produce a standardized di d coded DOFR, assisted by Sinaiko Healthcare coding consultant t Participants reviewed available DOFR resources and plan survey responses, developed guiding principles for DOFR completion, lti and assigned participants i t to research more complex areas Initial ldofr completed ltdlt late July 10
11 DOFR Webpage: html
12 DOFR Workgroup Product Standard set of service categories with associated codes NOT a standardized risk matrix risk assignment will still be determined by contract negotiations DOFR framework can encompass any consumer benefit design Not designed to assess value or cost per unit 12
13 DOFR Workgroup Product (cont d) DOFR template with 104 rows, 10,000 codes; 10 guidelines for use; future updates Excel workbook format Guidelines tab Recommended guidelines for contracting parties; review guidelines carefully before using DOFR Coding by service tab with financial responsibility matrix CDS Example tab Example of completed financial responsibility matrix Eight supplemental tabs for long code lists 13
14 Key Guideline Concepts Service category rows/coding provided to identify unambiguous service definitions and financial responsibility assignment; coding does not represent all possible combinations i Contracting organizations are expected to revise DOFRto fitspecific capitation/risk arrangement Transparency recommended Remove duplicate codes Break out or consolidate rows/columns as needed Some complex and/or ambiguous areas may need to be addressed outside of DOFR
15 Guideline Review
16 Coding by Service tab Supplemental tab references Plan to define DME, Injections, Office Supplies, Outpatient Surgery, Prosthetics, Orthotics In Area and Out of Area: Hospitalization, Observation, Physician Visits, Urgent Care and Second Opinion Second Opinion vs. Consultation Certain Radiology Codes (see Guideline 10)
17 Coding By Service Example
18 DOFR Implementation (1 3 years) 60 day comment period: Sept 26 Nov 26, 2011 DOFR use as reference documents in contracting DOFR embedded into commercial HMO/POS and Medicare Advantage contracts DOFR eventually becomes part of contracts management structures; embedded into claims systems
19 IHA Maintenance Plan IHA will maintain the DOFR for CA stakeholders to register and download DOFR work group convenes quarterly or as needed Updates to DOFR will occur: Post public comment periods to incorporate input Annually for scheduled updates (e.g., CPT updates) As needed for significant changes (e.g., migration to ICD 10)
20 Public Comment Period Currently in 60 day Public comment period that runs from Sept. 26 Nov. 26, 2011 Go to Submit your comments!! 20
21 Suggested Areas for Comment General Comments Guidelines Categories and Sub categories Financial i Responsibility Matrix Coding Detail Specific Questions Plan defined categories and duplicate coding Database format; other format enhancements Supplemental coding information Maintenance Plan
22 Q&A If additional questions regarding gdofr Webinar, contact: Nancy Hazlewood, DOFR Consultant Cindy Ernst, IHA Director Dan Cummins, IHA Program Manager
23
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