February 18 , 2008
A Wisconsin managed care network has used a provider portal and an internal workflow automation platform to lower administrative costs, eliminate paper, and improve provider relationships.
In today’s managed care arena, efficiency is key in enabling providers to act in a timely manner and for members to have suitable access to healthcare. However, manual processes can hinder efficiency to a great degree.
Dean Health Plan (DHP), a Madison, Wis.-based managed care network serving southern Wisconsin, found itself in the difficult position of having more requests for services than days to handle them. Julieanne Pofahl, DHP’s director of utilization management, knew something had to be done to mitigate the inefficient and time-consuming interactions with providers. She turned to Web-based communication as a means of making the dramatic improvements needed to manage care in a way that was beneficial to not only DHP but also to providers and members.
Kevin W. Carley, a partner in the Health & Life Sciences Group at Accenture who works on a national level with many large managed care plans, views Web-based communication as a valuable tool to improve real-time adjudication and information accuracy. “If you look at the market today on the national scene, most plans have Web-based transactions to varying degrees. From a health plan perspective, the Web is a channel for automation, but it is important to have multiple channels. Once you integrate the Web, then additional channels open up to integrate with the provider office for practice management and workflow improvements,” he says.
Previously, Pofahl says DHP had an all-paper process for authorizing requests, which caused several problems: insufficient staffing to handle paperwork; ineffective case and utilization management; numerous fax and phone call requests; customer service, providers, and members saddled with incomplete information requests; and limited ability to communicate and enforce changes to benefits or processes.
As a result, slow responses to requests led to a seven-day turnaround for requests. “January is our busiest month, where we were processing 8,000 referrals, so we knew we needed a system that would enable us to effectively adjudicate requests in a timely manner,” Pofahl says. “It was hard for our marketing department to say we were efficiently managing the care with seven days as the earliest we could get a request back.”
DHP embarked on a plan that aimed to improve market differentiation by eliminating ineffective internal workflows and cumbersome manual processes and finding a better way to communicate with providers and improve compliance.
Because DHP’s provider satisfaction survey identified referral process and compliance as continued provider pain points, it focused on improving its market position via better provider relationships and medical management processes. It also needed to improve efficiencies and lower costs by establishing more efficient processes and use of resources and decreasing administrative costs. Other goals were to make prior authorization processes transparent and improve member relationships.
DHP also sought methods to foster a more collaborative communications environment by extending information about its processes and rules into the provider office. By providing key information about such issues as eligibility and benefits, providers not familiar with DHP’s network or prior authorization requirements would have the information they needed for decision making simply by using the Web-based portal.
Pofahl says DHP’s business operations required customized technology to fit its unique internal and external business processes. Thus, the quest for a Web-based communication system began.
Taking the Leap
DHP sought a vendor with the right mix of flexibility, expertise, and partnership abilities. To help with the decision, it sought advice from the Gartner Group, a healthcare consulting firm that suggested a few companies, including NaviMedix, a Cambridge, Mass.-based company specializing in unifying electronic communications between healthcare providers and their business partners.
The proposal request sent to the suggested vendors featured questions germane to DHP’s needs, such as having partnerships with other IT vendors to create a full portal solution, as well as a deep knowledge of provider technology use in a practice setting. A group from DHP considered the responses, conferred with Gartner, and then chose NaviMedix. “We wanted a partner that could be flexible to allow us to create what we needed and who could understand our business and create a collaborative partnership,” says Pofahl.
DHP leveraged NaviMedix’ best practices expertise to create a DHP NaviNet that fit the health plan’s internal and external workflows. “Everything that requires medical management touch goes into NaviNet,” says Pofahl.
NaviMedix and DHP pinpointed processes that would benefit most from Web connectivity and worked closely to design the ideal workflow and lay out the necessary steps. NaviMedix created automated transactions specific to DHP’s unique business processes for prior, referral, and drug authorizations.
The Web-based communication and workflow automation platform improved provider and member relationships, decreased administrative costs, and upgraded case management functions.
“The benefits are really what we had hoped for when we put together the statement of need,” Pofahl says. “We reduced the budget for paper by two thirds over the last few years because we don’t have to send letters to providers, and the filing has decreased as well.”
By being able to take a more critical look at what was being reviewed and denied, DHP now handles 3,000 to 4,000 qualified referrals per month electronically compared with 8,000 manual referrals prior to NaviNet. This cuts down on paperwork even more.
“Automation, in general, provides for less paper and a decrease in cost. Elimination of paper is a key advantage. Improved customer service and improved quality of data are other big advantages that come with automation,” says Carley, who has seen these improvements firsthand among his clients.
Before NaviNet was implemented, DHP had an 11-step, seven-day process for completed requests. That process has been reduced to five steps that take one day to complete.
As a result of automation and other fine-tuning, DHP has experienced a 30% reduction in the total number of requests required. “The new turnaround time enhanced everyone’s perception of how efficient we are with the ability to take a request, make a determination, and send it instantly back to the provider with the member getting notification in an appropriate amount of time,” says Pofahl. Referrals are seamless, up to the minute, and actionable, and DHP is not in the way of the physician/patient relationship.
Previously, DHP’s call center received a high volume of simple requests, but now phone calls to utilization management have fallen by 27%, while customer service has realized a 37% reduction in calls.
When DHP began using NaviNet in 2004, it had 200,000 members. Since then, the improvements in workflow enabled DHP to reallocate 30% of its full-time nurses to case and disease management efforts. As membership grew to 260,000, the staff size has actually decreased by 20%.
“An intangible positive that came from this as well was a better relationship with providers and members,” Pofahl says, adding that the reduction in response time translated into a statistically significant increase in member satisfaction each year since 2004. This amounts to what Pofahl describes as a self-fulfilling cycle in which satisfied providers in turn use the solution more frequently.
At the same time DHP incorporated NaviNet on the medical management side, it did the same for pharmaceutical.
“We have the ability to put out to providers the criteria for drug authorization. Now, criteria for medical and drug authorization are evident to providers immediately. So if doing a consultation, a physician can check the criteria and choose an appropriate prescription for the patient,” says Pofahl. She says that with the sentinel of knowing that a prescription that doesn’t meet the criteria for authorization will be declined, there has been a decrease in such requests because physicians are making the appropriate requests the first time based on what they know will be authorized.
In addition, DHP has portals for members, providers, and employer groups that can pull up NaviMedix and the medical policies to gain information about coverage and benefits.
The biggest challenge Pofahl encountered in going to a Web-based communication system was in mapping NaviMedix to the appropriate data-entry claim system, which she says was a paradigm shift.
In addition, having sufficient IT resources to help make the move to a Web-based claim system was an issue. “Most everyone in our department is a doctor or nurse, and we’re not as well equipped as an IT specialist in Web-based approaches,” says Pofahl. “Rather than thinking it had to be all or nothing, we needed to understand we should get to the 80/20 rule, with 80% of requests being done electronically and 20% manually. Today, we’ve gotten to about a 95/5 rule.”
On the national scene, Carley has found that automation adoption rates have shown steady progress. “The amount of paper that flows through the system has been significantly reduced in the last 10 years. The Web is a piece of the automation strategy, among others, such as the use of EDI [electronic data interchange],” he says.
Carley says barriers to more widespread adoption include quality concerns in the transaction processing system and the inability to execute the transaction consistently in real time. Another barrier is the fragmented market in terms of technology in the provider’s space, where there are disparities in IT investment. In other words, it’s not one size fits all when it comes to providers selecting technology. “In comparing it to banking, where you can execute transactions on various Web sites and through computer applications seamlessly, it’s not yet at that level of ease for health plans adopting Web-based communication,” he says.
For those considering a move to Web-based communication, Pofahl offers a few suggestions. “Definitely do your homework to learn who is the best of breed and who has the ability—and more so, the desire—to go ‘out of the box’ to meet the needs of your organization,” she says, adding that there are many “canned,” prepackaged systems out there that expect you to adapt your system to theirs, which she said simply wouldn’t work for DHP. “I think we pushed NaviMedix in a direction they had never gone and because of that, I believe they adapted to our needs specifically,” she says.
Flexibility also rates high in Pofahl’s book. “For example, DHP is currently undergoing a systems conversion associated with the process. I have complete confidence in NaviNet that the conversion will be no problem,” she says.
Since the initial implementation, DHP has also experienced gains in case management functionality with the addition of a predictive modeling case management program in 2005, as well as a care management coordination component for members referred out of network. The system offers the flexibility to take on new processes and products, as well as the ability to prepare for future growth.
With the elimination of much of the paperwork, the savings in time and administrative costs, and improved provider and member satisfaction, Pofahl is pleased with DHP’s conversion to Web-based communication. “It has revolutionized our world,” she says. “We used to feel like we lived in the Dark Ages, and now we feel like we’ve moved to the 21st century.”
— Annie Macios is a freelance medical writer based in Doylestown, Pa.