Knowledge 3-23-16 Flashcards
How and What of Cost Calculations
Claims-based and derived from an ongoing analysis of client-specific claims. The process begins with 12 months of data,
All pricing data is derived from
Change Healthcare’s proprietary algorithms, which leverage allowed amounts and put historical and ongoing claims imports through a custom ETL (extract, transfer, load) process that looks for voids, adjustments and other inaccurate data points for removal.
How Specific? And what happens after Savings Engine mines the data?
Once the data has been scrubbed, our Savings Engine mines the data to identify a specific price (by plan and network), at a specific provider, for a specific service.
Price shown is the _________ amount?
Allowed
Allowed Amount
The total price paid to that provider for the service or prescription, for the member’s (user’s) specific network(s).
The Price or Costs are specific to?
Plan & Network
How Does Platform Display Price?
Platform shows the total cost for the service or prescription, with a break out of user’s cost and plan cost, based upon the user’s benefit plan and deductible status.
When network-specific pricing is unavailable?
Data from the surrounding region is used to determine an average expected cost.
From Internal Audits
95% within 5%
User or member cost is based on?
Users benefit plan & deductible status
How often is data refreshed?
Agreed upon frequencies
Accumulator files for benefit status
Typically provided on a weekly basis. But, for many health plan clients, we utilize EDI 270/271 transactions for real time accumulator information.
Cost data for Rx-where from?
claims, PBM supplied pricing lists, and generic saving program lists from pharmacy chains.
Pharmacy–area of differentiation
The frequency with which we intake claims data from the PBM. Claims are received and processed every other week to ensure the most accurate cost information, rather than monthly or bi-annually as is true of other transparency companies.
Pharmacy
We have the most experience in the transparency industry in managing pharmacy claims and in algorithms to identify opportunities for savings.
Reporting Frequency
Tied to the stage of the customer in the implementation process
1st 4 Weeks Reporting
During the first four weeks after implementation, reports are sent weekly and will be presented by your Account Executive.
Reporting post 1st Month
After the first month, we will move to monthly reporting.
Quarterly basis Reporting
We present a reporting package which incorporates consultative commentary around user engagement, as well as a roadmap view.
Comprehensive Annual Review
Includes our Claims-Verified SavingsTM, is held to compare results with stated goals.
Tableau
Deliver a monthly snapshot of your program metrics, including member search preferences, number of sign-ins, in addition to service, provider and prescription search statistics. You can even set-up your reports to deliver to your inbox every month.
Well Alerts Based On:
Client need and data analysis (using demographic data, claims history, member search data or data from client sponsored health and wellness programs).
Types of Well Alerts:
Preventive Services - founded on evidence-based medicineprotocols
Point of Care Utilization - to help members choose the best providers based on condition acuity and severity
Benefit Program Alerts - to help drive awareness of and engagement in disease management and wellness services
On-site Clinics - to drive utilization of clients’ on-site clinics and pharmacies; working with clients and listening to the challenges they face promoting healthcare consumerism has helped us understand that many of our customers struggle to educate their members on basic benefits
Provider Finder Overview
Enables members that are shopping for a health plan or are a current health plan member to easily search and compare: DSHIS
- doctors,
- specialists,
- hospitals,
- imaging centers,
- surgery centers and more in a user-friendly interface.
Provider Finder Search & FIlters
on quality, distance, gender, language and more.
Members can compare provider-specific detail such as
In- and out- of network flags (for multi carriers), locations, facility affiliation, quality ratings, credentials and special recognitions.
3 Primary Differentiators:
Data
Engagement
Integration
Data Differentiator
we have access to the single largest financial and administrative healthcare network in the U.S.
The Extensive Data allows us to:
provide highly accurate pricing information and more deeply personalize the way we present it to users to encourage their engagement.
With dataset, can leverage both:
commercial AND Medicare claims data to provide the most comprehensive view of provider procedure volumes, a key driver in provider quality and patient outcomes.
From Engagement Perspective
our ability to present data to the user in a highly personalized fashion, combined with our proactive approach to communication, drives market leading engagement rates averaging 60% across our book of business
Integration Flexibility
APIs, Partnerships, etc…
Where are the cost estimates are derived from?
recent claims data
Our proprietary algorithm factors in
a number of detailed plan, provider and timing elements to support accuracy of system estimates
More detailed quality metrics, such as
patient experience, credentialing, outcomes and efficiency measures.
How Often does Change Review Quality Data?
Each quarter, Change Healthcare does a thorough review of existing quality data sources and is continually evaluating additional quality data and data provider sources that meet evolving market needs.
Who Provides Quality Data?
Provider Ratings (physicians, dentists and chiropractors) are provided by Strenuus, HHS and Health Plan credentialing. Facility Ratings are provided by HHS, AHRQ, HCAHPS and The Joint Commission.
Data Sources 1
Member eligibility data: Typically sourced from an eligibility feed.
• Accumulator data: Typically sourced via a real-time EDI 270/271 (eligibility) call routed to the medical carrier.
• Benefit data: Typically sourced from a 270/271 transaction with supplemental information provided by the plan as business rules dictate.
• Provider data: Used when business rules dictate special processes at the provider level. Typically provided in a file on an agreed upon frequency.
Data Sources 2
Formulary: Typically provided by a PBM or plan on a monthly basis.
• Service Cost: Sourced primarily from client claims and supplemented with contract rates and/or book of business claims where available.
Provider Quality Includes data from:
The largest group of annual studies of hospital quality, physician information and patient experiences available in the U.S., including nationally aggregated ratings for providers and hospitals, and patient care interaction data across 5,000 hospitals and 2 million healthcare professionals.
What % of Providers on platform have quality data?
Change Healthcare’s quality data covers 75% of providers available in our database, including facilities, doctors and dentists.
