Dell Healthcare Services Grievance and Appeals Management

Grievance & Appeals Management Dell Healthcare Services

BPO Capability Overview

Dell - Internal Use - Confidential

Member/Provider Grievance & Appeals

Presentation Content:

• High-level process flow in member/provider G&A

• How Dell can help in member/provider G&A

• Customer examples

• DBMS—Reporting and Analytics

• Pricing Methodology Dell’s proven history of supporting health plans through leading edge technology, scalability of operations, and process efficiency

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Member G&A – a high level process flow

Standardized data collection

Case acknowledgement

Communication to member

Case follow-up and closure

Case research and analysis

DBPMS audit tool

DBPMS reporting & analytics

DBPMS Workflow

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Member G&A – A Dell Services BPO Perspective

• Case acknowledgement letters are not required under federal regulations, but are a “best practice” which help to provide timely and accurate information to members

• Acknowledgment letters contribute to overall efficiency by reducing the number of follow-up inquiries from members

• Correctly classify issue as either an appeal, a grievance, or both, and process accordingly • Correctly determine whether an issue should be handled on a standard or expedited basis, adhere to

processing timeframes accordingly • Analyze and research cases to make final determinations on appeals and provide comprehensive

responses within contractual and regulatory timeframes

• Standardized data collection processes are a “best practice” which allow for more efficient and effective internal and external audits

• Standardized format improves overall data analysis by allowing the company to compare specific variables such as grievance type, turn around time, etc.

• Monitor all cases and complete appropriate action necessary to close cases • Ensure robust case documentation from start to finish • Protect member confidentiality by obtaining third party consent as necessary • Utilize appropriate authorization forms

• Meet or exceed timeliness standards for notification and turnaround as specified by federal regulations including, but not limited to: Medicare Managed Care Manual Chapter 13 and Prescription Drug Benefit Manual Chapter 18

Case acknowledgment

Case research and analysis

Standardized data collection

Case follow-up and closure

Processing time 4 of 17


Provider G&A – a high level process flow

Intimation letter to providers

Multiple intake channels

Case triaging

Correspondence to providers

Critical handling of 3rd/4th level appeals

Case review, follow-up and closure

DBPMS reporting & analytics

DBPMS audit tool

DBPMS Workflow

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Provider G&A – A Dell Services BPO Perspective

• All cases are triaged to determine whether an authentic appeal or grievance exists – If no authentic appeal or grievance exists, the issue is properly categorized and rerouted to

another queue

• G&A specialists gather all documentation from the denial/appeal and evaluate the case using any new information or documentation submitted with the appeal

• Providers are contacted if additional documentation is required • A fair and independent review is conducted to either uphold or overturn the prior decision • If payment is to be made, the case is rerouted to the claims queue • If the denial is upheld, a legal letter is mailed out to providers

• Dell specialists collect potential G&A cases received via web-portal, Fax and Mail • Mail is scanned, digitized, and uploaded into plan’s system • All cases are loaded to DBPMS to be allocated to the triage queue

• All decisions are completed within the 30-day TAT or any other contractual timeline stipulated

• Dell G&A Specialists can also handle 3rd or 4th level appeals which require thorough investigation, research and critical judgment

Case triaging

Case review, follow-up and closure

Intake channels

Processing time

3rd or 4th level appeals and grievance

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Enhancing performance quality with reporting & analytics

Reporting Analytics

• Dell uses its proprietary tool, Dell Business Process Management Suite (DBPMS) for external and internal reporting

• Our ability to provide actionable data helps plans to be more efficient and cost effective, and also helps plans to improve/maintain 5-star ratings

– Ability to provide actionable data also reduces the risk of plans being reported as CMS outliers

• External reports are generated to ensure compliance with state and federal regulations

• Analysis of common grievance and/or appeal types may drive improvements to internal procedures

• Analysis of turnaround time and other regulated elements ensures a consistent evaluation of compliance

• The internal reports and data analytics help to drive smart business decisions, reduce appeals and improve process efficiency

• Examples of data that drive quality improvements: – Trends in appeal category and sub-category – Trends in first level overturned appeals – Trends in IRE overturned appeals

Driving quality improvements

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Provider Grievance & Appeals experience

Dell has experience to quickly staff, train and manage member appeals and grievances specialists, as well as provider resolution processors

Harvard Pilgrim Health Care Texas-based, multi-state

Medicare advantage plan provider

• Providing appeals and grievances specialists since June 2011, averaging 12 specialists onsite during this time

• The appeals specialist are be responsible for assembling decision making materials from the prior denial and evaluating that criteria with any new information or documentation submitted with the appeal

• The appeals specialist completes a fair and independent review and make a determination about the prior denial whether to uphold or overturn that decision

• In 2008, Harvard Pilgrim Health Care (HPHC) expanded its BPO relationship with Dell and transitioned support for multiple new functions including provider relations and provider call center – this included supporting the provider appeals and grievances processes

• Dell transitioned/re-badged 44 HPHC resources as part of assuming responsibility for these functions

• We have a 30-day TAT goal to process provider appeals from receipt of the appeal to date of the appeal response/letter to the provider

• The letter notifies the provider of appeal disposition which could be either "upheld" or "approved“

• We have consistently achieved or exceed the standard metric of 95% of provider appeals being processed within 30 days

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DBPMS: Reporting & Analytics

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Dell Business Process Management Suite (DBPMS) End-to-end service delivery & transformation tool

Workflow Manage and optimize workflow productivity and quality using a skills-based routing logic and collaboration across the chain in secure and quality environment% Improves process control, productivity, and quality by 10-15%

Knowledge management & Learning Portal

Combines process guidance tools, self-service learning management portals, and testing applications Improves quality by 15-20%

Client Extranet/ Global Collaboration Portal

Web-enabled collaboration and reporting tool. Improve process governance and collaboration, and enables global collaboration Improves process governance, CSAT, and improves transparency

The Foundational Work Process Management Layer

Reporting & Dashboards Power-packed multi-dimensional analytics on process health indicators/KPIs, Enables informed decision making

Automated Full Time Employee 50+ industry leading robotic automation methods and tools. Improves productivity and quality of processing by about 10-15%

The Process Transformation Layer

Integration Layer Accept process inputs via multiple file formats including XML, CSV/TXT, PDF, Images, or word document files as well as work with market leading integration tools

Access Layer Application design is compatible with most mobile browsers and includes apps for android and iOS

Integration and Access Layer 10 of 17


Dell Business Process Management suite Operations Leadership Dashboard

Highlights

• Parameters evaluated

– Capacity Utilization

– Turn Around Time

– Production/ Productivity

– Seat Utilization

– Absenteeism

– Attrition

– My Time

– Quality

– Job Knowledge

– Performance Metrics

• Weekly review by the team leaders

=> 99%

95% to 98%%

< 95%

TL Dashboard- Overall Performance TL Dashboard – Capacity Utilization

TL Dashboard – Turn Around Time TL Dashboard – Quality Metrics 11 of 17


DBPMS – key benefits

• Effective monitoring and controlling of business process

• Manager dashboard to manage day-to-day operations – track SLAs and TAT, etc.

• Powerful reporting ability with configurable report generator to create reports on the fly

• Form builder feature to create modules based on processes and sub-processes

• Client extranet for easy tracking and quick solution for the queries raised by onshore, offshore and client teams

• Transparency in operation between client and BPO teams

• Better integration with automation processes and improvement in productivity

Manager dashboard for day-to-day operations

RepGen – report generator 12 of 17


DBPMS – reporting & analytics capabilities

What happened?

How many? How often? Where? Ad-hoc reports

What exactly is the problem?

Query drill

down

What actions are needed?

Why is this happening?

Alerts

What if these trends continue?

What will happen next?

What is the best can happen?

Degree of intelligence

Co

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tiv

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tag

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modeling

Standard reports

Statistical report

Optimization

Forecasting

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Value-added delivery tools from DBPMS

Dashboards

Knowledge portal

Screenshots from existing BPO process 14 of 17


Value-added delivery tools from DBPMS

Screenshots from existing MA BPO process Workflow

Productivity improvement

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Why Dell Services?

Dell’s proven history of supporting health plans

Leading edge technology

Technology enablers/overlay tools

Increased scale of operations through blended shore delivery

Increased process efficiency and effectiveness

Global delivery model provides cost alternatives to meet our client’s needs

6 sigma, Lean, Kaizen, to make processes more agile, optimized and proficient

Strategic partnerships to bring in best in class technology

DBPMS our wrap-around suite of tools to drive greater efficiency and optimize performance

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Thank you!

Visit Dell.com/HealthPlans to learn more.

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