medicaid information technology architecture (mita) where louisiana medicaid is today and where it...
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Medicaid Information Technology Architecture(MITA)
Where Louisiana Medicaid is Today and Where it Will To Be in the Future
April 17, 2012
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What is MITA
• (MITA) is an initiative of the Center for Medicaid & State Operations (CMSO). MITA is intended to foster integrated business and IT transformation across the Medicaid enterprise to improve the administration of the Medicaid program. The MITA Initiative is a national framework to support improved systems development and health care management for the Medicaid enterprise.
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Where MITA can be found
Navigate to: www.medicaid.gov
Click on “Medicaid & CHIP Program Information” tab
Look under “Medicaid Information by Topic”
Click on “Data & Systems”
Go to “Medicaid Information Technology Architecture”
Go to “MITA 3.0 Downloads”
Direct Link to MITA
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Goals of MITA
Develop seamless and integrated systems that effectively communicate.
Achieve Common Medicaid goals through interoperability and shared standards.
Promote an environment that supports flexibility, adaptability, and rapid response to changes in programs and technology.
Promote an enterprise view that supports enabling technologies aligned with Medicaid business processes and technologies.
• Provide data that is timely, accurate, usable, and easily accessible to support analysis and decision making for healthcare management and program administration.
• Provide performance measurement for accountability and planning.
• Coordinate with public health and other partners to integrate health outcomes within the Medicaid Community.
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LA Medicaid Goals
The goals of the Bureau of Health Services Financing are to:• Improve health outcomes by emphasizing primary care and
reducing the number of uninsured persons in Louisiana• Expand existing and develop additional community-based
services as an alternative to institutional care• Ensure cost effectiveness in the delivery of health care
services by using efficient management practices and maximizing revenue opportunities
• Assure the integrity and accountability of the health care delivery system in an effort to promote the health and safety of Louisiana citizens
• Implement measures that will constrain the growth in Medicaid expenditures while improving services to secure alternative sources of funding for health care in Louisiana
• Streamline work processes and increase productivity through technology by expanding the utilization of electronic tools for both the providers and the Medicaid Administrative staff
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Key Concepts of MITA• Maturity Model- Describes how Medicaid operations
mature over time by defining the characteristics of five levels of improvement.o As-Is= Maturity level of 1, 2-3 years =Maturity level of 2, 5 years =Maturity
level of 3, 7-8 years equals maturity level of 4, 10 years = Maturity level of 5
• Business Process Model-defines a set of common business processes used across Medicaid.o Eight Business Areas: Member Management, Provider Management,
Contractor Management, Operations Management, Program Management, Care Management, Performance Management, Business Relationship Management, Eligibility & Enrollment Management and Plan Management.
• Business Capability Matrix- Defines the maturation characteristics for individual business processes. o i.e. Changing rates for providers from a manual process to an automated
one
• State Self Assessment (SS-A)-asks states to compare current business operations, technical capabilities and targeted levels of improvement.
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Current Louisiana Medicaid Operational Structure
Supplemental Payments
Rate and Audit Managed Care Eligibility Field Operations
Policy Development and Implementation
Waiver Compliance
Center for Health Reform Initiatives
Eligibility Policy
Medicaid Management Information System
Program Integrity
Eligibility Supports
Recovery and Premium Assistance
Financial Management & Operations
Health Standard Pharmacy Program
Eligibility Systems
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Vision of Medicaid Operations Aligned Through MITA
Member Management
Eligibility and Enrollment Management
Provider Management
Contractor Management
Operations Management
Program Management
Plan Management
Care Management
Performance Management
Business Relationship Management
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Business Process Model
• Business Relationship Management is a collection of business processes that facilitates the coordination of standards of interoperability.
• Care Management collects information about the needs of the individual member, plan of treatment, targeted outcomes, and the individual’s health status.
• Contractor Management business area has a common focus on Medicaid contractors (e.g., managed care, at-risk mental health or dental care, primary care physician), is responsible for contractor data store, and uses business process that have a common purpose (e.g., fiscal agent, enrollment broker, Fraud Enforcement Agency, and third-party recovery).
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Business Process Model …
• Eligibility and Enrollment Management is a collection of business processes involved in the activity for determination of eligibility and enrollment for new applicants, redetermination of existing members, enrolling new providers, and revalidation of existing providers.
• Financial Management is a collection of business processes to support the payment of providers, managed care organizations, other agencies, insurers, Medicare premiums and financial participation.
• Member Management is a collection of business processes involved in communications between the SMA and the prospective or enrolled member and actions that the agency takes on behalf of the member.
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Business Process Model …
• Operations Management is a collection of business processes that manage claims and prepare premium payments.
• Performance Management is a collection of business processes involved in the assessment of program compliance (e.g., auditing and tracking medical necessity and appropriateness of care, quality of care, patient safety, fraud and abuse, erroneous payments, and administrative anomalies).
• Plan Management includes strategic planning, policymaking, monitoring, and oversight of business process for the agency.
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Business Process Model …
• Provider Management is a collection of business processes that focus on terminating providers, communications with providers, dealing with provider grievances and appeals issues, and performing outreach services to providers.
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Work Plan
Tasks Time Frame
Update/Verify the “Charting” of the Business Processes
Information passed out during the Kick-Off Meeting and continually enhanced during the process
Assess the 2.1 MITA “To Be” Business Process Model and Business Capability Matrix
Information passed out during the Kick-Off Meeting and continually enhanced during the process
Conduct rotating, regularly scheduled meetings with the SMEs
Continues during the process
Conduct a Gap Analysis To be completed in conjunction with the rotating SME meetings
Update the 3.0 MITA “As Is” SS-A Completed by the end of September 2012
Update the 3.0 MITA “To Be’ SS-A Completed by the end of September 2012
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Work Plan …
• Conducting a Gap Analysis between our MITA 2.1 SS-A and the MITA 3.0 SS-A
Taking our MITA 2.1 SS-A “To Be” Document
Assessing The Level We Want “To Be “ For Each Business Process Based On MITA 3.0 Categories
Documenting The Difference In Getting To Where We Want “To Be”
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Work Plan …
• Converting our 2.1 “To Be” MITA SS-A to both a 3.0 “As Is” MITA SS-A and a 3.0 “To-Be” MITA SS-A
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Steps/Actions Needed to Move to the “To Be”
1. Devise a plan to determine what steps are necessary to meet our goals.
2. Set benchmarks/timeline to implement plan.
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Mapping to the 3.0 MITA Business Process Areas
Louisiana Business ProcessesMITA 2.1 Business
Process AreaMITA 3.0 Business
Process AreaLouisiana Medicaid Operation
StructureDetermine Eligibility Member ManagementDisenroll Member Member ManagementEnroll Member Member ManagementInquire Member Eligibility Member ManagementManage Applicant and Member Communication Member ManagementManage Member Grievance and Appeal Member ManagementManage Member Information Member ManagementPerform Population and Member Outreach Member ManagementDisenroll Provider Provider ManagementEnroll Provider Provider ManagementInquire Provider Provider ManagementManage Provider Communication Provider ManagementManage Provider Grievance and Appeal Provider ManagementManage Provider Information Provider ManagementPerform Provider Outreach Provider ManagementAward Contract Contractor ManagementManage Contract Contractor ManagementClose Out Contract Contractor ManagementManage Contractor Information Contractor ManagementManage Contractor Communication Contractor ManagementSupport Contractor Grievance and Appeal Contractor ManagementInquire Contractor Information Contractor Management
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Questions
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