key revenue management with increasingly scarce resources
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Key Revenue Management Ini0a0ves with Increasingly Scarce Resources
March 18, 2014
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Overview
! Complexity of Revenue Management ! Key Revenue Management Ini0a0ves ! Revenue Management Strategies ! Resources Needed for the Ini0a0ves ! Using Health Plan Resources versus Vendors ! Reason for Scarce Resources ! Impact of Scarce Resources ! Recommenda0ons for Success
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Complexity of Revenue Management
! Mul0ple disciplines are involved
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Complexity of Revenue Management
! Mul0ple disciplines are involved
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Complexity of Revenue Management
! Mul0ple disciplines are involved
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Complexity of Revenue Management
! Mul0ple disciplines are involved
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Complexity of Revenue Management
! Need coordina0on across disciplines: ! Success depends on effec9veness across the enterprise ! Skilled resources needed in each area ! Only as successful as your weakest link ! Compe9ng plan demands for each area’s 9me and resources
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Key Revenue Management Ini0a0ves
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Key Revenue Management Ini0a0ves
! Encounters Submission ! Collec9ng, FormaIng, and SubmiIng the Data ! Correc9on of Errors based on Response Files
! Maintaining Source Data ! Member Eligibility, Claims, and Provider Data
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Revenue Management Strategies
! Clinical Review of Risk Score Gaps ! Focus on chronic condi9ons and filter out acute ! Determine probability member has chronic condi9on
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Revenue Management Strategies
! Iden0fy Sources of Nega0ve Revenue Impact ! Determine nega9ve revenue impact by provider groups ! Compare provider submission stats and documenta9on quality
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Revenue Management Strategies
! Mine Results for Refining the Targe0ng Algorithm ! Determine Provider ROI ! Determine Provider HCC Persistency
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Revenue Management Strategies
! Predic0ve Analy0cs ! Use of pharmacy and other supplemental sources ! Iden9fy suspect condi9ons that have never been reported
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Resources Needed for The Ini0a0ves
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Using Health Plan Resources versus Vendors
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Health Plan Vendor
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Reason for Scarce Resources
! Con0nually changing government regula0ons ! Changes are assured to occur every year ! Some9mes change is dras9c with a very short 9me frame
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Reason for Scarce Resources
! High Degree of Complexity ! Need skilled resources with experience in many areas ! Data-‐driven analy9cs, and technology intensive work ! Most plan resources wear mul9ple hats and are spread thin
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Reason for Scarce Resources
! Managed Care Plan Challenges ! Must excel in core competencies to provide member care ! S9ll need staff to support func9ons all companies have: accoun9ng, sales, marke9ng, finance, customer service, etc.
! Mul9ple Lines of Business with very different regula9ons
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Examples of Changing Government Regula0ons
! CMS Medicare Payment Year 2015 Advanced No0ce ! Con9nua9on of the blended payment year model ! Introduc9on of an ICD-‐10 crosswalk post October 1 ! Home health assessments need subsequent provider visit ! 3 Star underperforming plans may be terminated
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Examples of Changing Government Regula0ons
! HHS Commercial Benefit Year 2014 ! Healthcare.gov technical issues delayed enrollment ! REGTAP delays and Edge Server uncertainty clouds 9meline ! Funds transfer formula outcome difficult to predict in advance
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Impact of Scarce Resources
! Con0nuous string of projects due to rapid change ! High degree of subject maaer exper9se needed to keep up ! Huge industry wide impacts such as HIPAA and ICD10
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Impact of Scarce Resources
! Complexity of Projects Makes Everything Go Slower ! Lack of skilled and experienced SME’s are a limi9ng factor ! Many discussions needed at a very detailed level ! Lack of availability of SME’s in any area hinders whole project
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Impact of Scarce Resources
! Managed Care Plan Never Ending Challenges ! Work volume and rate of change means resource overload ! Resources stretched thin across departments and LOBs. ! Turnover of any key resources has a drama9c impact
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Recommenda0ons for Success
! Know the Strengths and Skills of Your Resources ! Aligning tasks based on strengths drives efficiency ! Knowing strengths also determines areas of weakness
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Recommenda0ons for Success
! Consider Vendors Based on Plan’s Resource Gaps ! Leverage internal resources where possible and cost effec9ve ! Recognize gaps in skills, experience, resources, or capabili9es ! Look for value, reputa9on, and right-‐sized solu9ons
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Recommenda0ons for Success
! Re-‐Evaluate Revenue Management Every Year ! Nothing is the same year to year and revenue management should not be the same either
! Every year brings different challenges in different areas ! New and exis9ng vendors change capabili9es every year, so choose wisely
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