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DIVA Solutions, LLC – Proprietary 1
North Jersey IIA Software Expo
Data Mining-driven Eligibility, Dependent Eligibility and
Claims Auditing
May 17, 2007
DIVA Solutions, LLC – Proprietary 2
Contents
Introductions and Overview
The Business Case
Audit Survey Responses and Case Studies
Web-based Technology
Next Steps
DIVA Solutions, LLC – Proprietary 3
Introductions and Overview
2001 2002 2003 2004 2005 2006 2007
Eligibility
Rx Claims
Medical Claims
Clinical and Disease Management Audit
Case Management Audit
Dependent Audit
Web: Eligibility Auditing
DIFFERENTIATORS• Comprehensive • ROI-driven• Independent• 100% Data
• Data Mining• Root Cause• Passion
DIVA Solutions, LLC – Proprietary 4
Census COBRA Rx
SuspectsReports
MemberData Warehouse
Cleanse
Load
Query
Business/Audit Needs:
• Eligibility• Dependent Eligibility• Subrogation• Discounts• Financial• Limits• Exclusions• Rx rebates• Other
Enrollment Medical
Introductions and Overview -Technology Model
SPDs, ASO Contracts and Reports
DIVA Solutions, LLC – Proprietary 5
The Business Case
ITEM 2007 2008 2009 2010
Current Budget (w/o audit) $30,000,000 $33,000,000 $36,300,000 $39,930,000
Audit Improvements ** $30,000,000 $32,340,000 $35,574,000 $39,131,400
Dependent Eligibility Audit Improvements *** $30,000,000 $32,010,000 $35,211,000 $38,732,100
Claim Audit Savings $660,000 $726,000 $798,600
Dependent Audit Savings $990,000 $1,089,000 $1,197,900
Total Program Savings $1,650,000 $1,815,000 $1,996,500* Excludes recoveries from payor** Includes a 2% reduction in spend plus a 10% trend *** Includes a 3% reduction in spend plus a 10% trend
DIVA Solutions, LLC – Proprietary 6
Survey Responses and Case Studies –Why Perform an Audit?
RESPONSE EXAMPLE
#1 – Recapture overpayments ESRD Medicare
#2 – Contain future costs Point-in-time Eligibility
#3 – Identify root cause improvements Subrogation
#4 – Contribute to vendor negotiations
#5 – Perform due diligence
DIVA Solutions, LLC – Proprietary 7
Survey Responses and Case Studies –Which Medical Areas Should Be Audited?
RESPONSE EXAMPLE
#1 – Discounts (consistent across all responses) N/W Discounts & Access Fees
#2 – Limits and exclusions Gastric Bypass
#3 – Stop loss Plan Year Straddle
#4 – Member liability
# 5- Employee eligibility Low Hours
#9 – Subrogation and coordination of benefits
DIVA Solutions, LLC – Proprietary 8
Survey Responses and Case Studies –Which Rx Areas Should Be Audited?
RESPONSE EXAMPLE
#1 – Limits and exclusions Biotech
#2 – Discounts AWP – Marketing Vs. Contract
#3 – Rebates Contract – In/Out
#4 – Member Liability Systemic Co-payment
#5 – Stop Loss
DIVA Solutions, LLC – Proprietary 9
Survey Responses and Case Studies –What Are The Top Attributes?
RESPONSE FACT
#1 – Data Warehousing Technology Data Mining/web
#2 – Specific Payor Experience National Payors/PBMS
#3 – Cost
#4 – Performance Guarantees 100% ROI +
#5 – Return On Investment Several Hundred %
Web-Based Technology: Eligibility Dashboard ExamplePlan statistics as well as query summaries are provided in the Dashboard Summary
Users can refine the standard query selection criteria by changing the search criteria
The query result can be easily downloaded to Excel for further analysis
Web-Based Technology: Beyond Termination Example In this example we looked for claims greater
than $200 and term dates after Sept. 1, 2005
Web-Based Technology: Low Premium Example
This query identifies tier mismatch suspects
Employees are presented their dependents and are asked to confirm eligibility
Alternatively, employees can be prompted with “fill-in-the blank” questions regarding their dependents
Employees can be asked questions about spousal employment and their respective benefits insurance or questions regarding their college age child to ensure eligibility
Web-Based Technology: Dependent Confirmation Web Page
Member activity metrics are available24/7 via the web
The actual savings based upon claimspend is available 24/7 via the web. SavingsAlso be computed on a per-capita basis
The actual savings by relationshiptype is available 24/7 via the web
Web-Based Technology: Dependent Audit Dashboard - 24/7 ROI
Web-Based Technology: Departmental Healthcare Spending
Our system also helps users understand member spend by organizational unit
DIVA Solutions, LLC – Proprietary 16
Next Steps Stop by our booth
Ask us about potential leakage in your plan
Contact
Howie Gerver at 201.891.8010 or, [email protected]; or
Ed McDermott at 201.818.9196 or [email protected]
Thank you for your time and interest!
