Payors’ Updates & Predictions
October 2012
Agenda










Provider Relations and Network Contracting
Updating your records
HIPAA 5010 and ICD-10
UnitedHealthcareonline
STARS
View 360
ER
Hedis and EPSDT
Network Bulletin
Our Service Model and PCRS
2
Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Network Contracting and
Provider Relations
The Right Resource at The Right Time
Physician/Facility Advocates
 Issue resolution for service
failures
 Education
 Liaison for physicians and
all UHC business segments
Network Contracting
 New agreements
 Renewals
 New product adds
 Contract questions
 Physician/Facility set up
3
Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Updating your Records
Practice-Facility Updates - (877) 842-3210
Maintaining your contact and billing information is critical to
receive important updates regarding procedure and policy
changes, useful administrative information and timely delivery
of your claims payments. You can update or submit your
Practice-Facility information online, by fax or telephone. For
Tax ID updates, submit using the fax form and include a W-9.
- Online - using Practice-Facility Updates
- Fax - download appropriate form for submission
- Telephone - UnitedHealthcare for Health Care
Professionals line (United Voice Portal) at (877) 842-3210,
say "health care professional services", then "demographic
changes."
4
Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
HIPAA 5010
On March 15, 2012, the Centers for Medicare & Medicaid Services'
(CMS) Office of E-Health Standards and Services (OESS)
announced that it would postpone enforcement of its mandate to
use 5010 standards in electronic transactions.
The final 5010 implementation deadline was July 1, 2012
UnitedHealthcare continued to accept 4010 electronic transactions
until July 1, 2012 and also accepted transactions using the 5010
standards during the transition time period.
5
Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
ICD-10
HHS has announced a proposed rule which will set the
ICD-10 implementation date for October 1, 2014
Why the delay?
• Industry transition to Version 5010 did not proceed as
effectively as expected
• Providers expressed concern that other statutory initiatives
are stretching their resources
• Surveys and polls indicated a lack of readiness for the
ICD-10 transition
6
Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Benefits of ICD-10 Implementation
Transitioning to ICD-10 can result in significant value realization
7
Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
HIPAA 5010 and ICD-10
8
Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
9
Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
A Changing Health Care
Landscape
• New regulations, political forces and patient
expectations are changing health care in America
• Health plans and physicians are being called on
to close gaps in care and improve overall quality
• And increasingly, the Centers for Medicare and
Medicaid Services (CMS) is moving to tie
reimbursement for Medicare services directly to
patient outcomes
• Together, we can help Medicare beneficiaries get
the most from their benefits --- meaning better
use of limited resources and more satisfied
patients for you and your practice
10
10
Proprietary
Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
UHC:
0615s_02201202
What Does Quality Look and Feel
Like?
By improving performance in:
• Diabetes management
• Medication management after
a heart attack
• Controlling high blood
pressure
• Medication management
• Managing antidepressant
medication
• Testing to diagnose COPD
• Complaints and appeals
• Call center customer service
More Medicare beneficiaries are:
• Preventing complications
• Maintaining an appropriate
medication regimen
• Lowering their risk of stroke
and heart disease
• Maintaining an appropriate
drug regimen
• Protecting mental health and
well being
• Managing their condition
• Resolving issues faster
• Getting what they need, the
first time they call
11
11
Proprietary
Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
UHC:
0615s_02201202
Quality is Measured in Many Ways
National measurement programs
reflect different dimensions of plan
performance and health outcomes
Emphasize physician collaboration
and patient engagement
Industry quality programs include:
HEDIS (Healthcare Effectiveness Data and
Information Set)
CAHPS (Consumer Assessment of Healthcare
Providers and Systems)
HOS (Health Outcomes Survey)
NCQA Accreditation
Medicare Star Ratings
12
12
Proprietary
Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
UHC:
0615s_02201202
What are Medicare Star Ratings?
• CMS publishes Star Ratings
annually to help consumers
compare Medicare Advantage
and Prescription Drug plans
• Plans are scored and paid by
CMS based on their overall
Star Rating performance
Excellent
Very Good
Good
Fair
Poor
• Ratings emphasize patient care
and satisfaction, using national
clinical and service quality
measures, health outcomes
and patient feedback about
their health care experience
13
13
Proprietary
Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
UHC:
0615s_02201202
2012 Medicare Star Ratings:
53 Quality Measures
• Includes patient experience and their
perception of their health
• Part D (Drug Coverage) - 17 measures
– Customer service
– Complaints and members leaving the plan
– Member experience - getting information and
drugs
– Pricing and patient safety
• Part C (Medicare Advantage) - 36 measures
–
–
–
–
–
Staying healthy
Chronic condition management
Responsiveness and care
Complaints and members leaving the plan
Health plan operations and customer service
14
14
Proprietary
Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
UHC:
0615s_02201202
HEDIS
Healthcare Effectiveness Data and Information Set
HEDIS® is the gold standard in health care performance
measurement, used by more than 90 percent of the nation's
health plans and many leading employers and regulators .
HEDIS ® is a set of standardized measures that specifies how
organizations collect, audit and report performance information
across the most pressing clinical areas, as well as important
dimensions of customer satisfaction and patient experience.
15
Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
HEDIS
HEDIS ® makes it possible to compare the
performance of health plans and further allow Health
plans to use the HEDIS results to focus their efforts for
improvement.
HEDIS ® measures address a broad range of important
health issues. Among some of these issues are, but not
limited to:
Controlling High Blood Pressure
Comprehensive Diabetes Care
Breast Cancer Screening
*Copyright
2009, NCQA
16
Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
EPSDT/Health Check
Medicaid's Early and Periodic Screening, Diagnostic, and
Treatment (EPSDT) Program is a preventive primary health care
program for eligible low-income children and teens ages birth to 21.
EPSDT emphasizes preventive care, especially screening services, to
promote good health and identify and treat problems early and
effectively.
EPSDT is a joint federal-state partnership program administered by the
Centers for Medicare & Medicaid Services (CMS). The program has
two operational components:
Assuring the availability and accessibility of required health care resources
Helping Medicaid recipients and their parents or guardians effectively use
these resources
CMS, state Medicaid agencies, and EPSDT providers have a shared
obligation to ensure comprehensive pediatric preventive care for
eligible children and teens, and to support their families in accessing
the health services available through EPSDT.
17
Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
EPSDT/Health Check
Required EPSDT Health Services The EPSDT program mandates
the following preventive health services:
Screening services
Comprehensive health and developmental history (physical, mental,
and developmental)
Comprehensive unclothed physical exam
Appropriate immunizations
Laboratory tests, including mandatory lead screening
Health education and anticipatory guidance
Vision screening
Hearing screening
Dental screening
Other necessary health care
Diagnostic services, if needed for further evaluation
Treatment (or referrals) to correct or improve health conditions
18
Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Physician Collaboration: View360
• Provides online, instant
access to patient’s
history
• Helps identify who may
need recommended
screenings, treatments
or exams
• Is updated monthly,
providing timely and
actionable information
• Fits into your busy
routine and workflow
• Displays up to 3 years of
claims history, including
prescriptions and lab
work
19
Proprietary
Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
UHC:
0615s_02201202
View 360
20
Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Emergency Room
Controlling Emergency Room Usage is Everyone’s
Responsibility
Offices should have clear procedures for patients to access
physicians or care after hours or on weekends
Voicemail messages should provide all available options not
just direct patients to the ER
Patients with established patterns of inappropriate ER usage
should be referred to UHC for additional patient education
21
Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Escalated Service Model
Provider
website
United
Voice Portal
Provider
Phone
Representative
Escalated
Service LineProvider Phone
Rep
Escalate to a
Network
Account
Manager or
Advocate if
Unresolved
First Step
•Submit claim adjustment and make note of document
Provider Web Portal
United Voice Portal
tracking number (15-digit C number; not available when
reconsideration is mailed)
•Online via UnitedHealthcareOnline.com >Claims &
Payments > Claim Reconsideration
•Via United Voice Portal at 877-842-3210
•Mail claim reconsideration form to claim address on
member health care ID card
Second Step
•Check claim status to see if claim has been reprocessed;
Provider Phone
Representative
Escalated Service
Line- PPR
please allow 20 days for processing or reprocessing of claim
•If claim is not resolved, please escalate to your local
UnitedHealthcare Network Account Manager if contract
related or your Advocacy team if claim related.
•To find your Network Account Manager, go to the contact
us section of www.unitedheatlhcareonline.com.
•The Advocacy Team can be reached at
MidAtlantic_PR_Team@uhc.com.
22
Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Commercial Provider Service PCRS Model:
What’s the difference (eff 2-6-12)
Legacy model
PCRS model
Customer Service (PPR)
interprets claim and decides
expectation for the provider
Customer Service (PPR) will
ask and document what the
provider’s expectation is (i.e. –
No callback made to close
issue
PCRS callback when the
provider’s expectation is not
met
Issues are routed and visibility
into resolution
End-to-end model is owned by
the PCRS team
High number of repeat calls
Reduction in repeat calls
“how much do you expect for payment”)
23
Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
The Network Bulletin
24
Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
25
Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.