Managed Care Resources, Inc. Newsletter

June 2001 Volume 1, Issue 1

One of the goals of our newsletter is to share with you our experience with real issues facing real organizations. We will keep our clients' identities confidential, while trying to share experiences from working with our clients.

One area of growing interest among our clients is the use of operational assessments in evaluating the effectiveness and identifying areas for improvement. HMOs, PHOs, IPAs, medical groups, and even hospitals are using the findings to identify different improvement strategies.

When To Conduct Assessments

Assessments should be a regular event conducted every 2-3 years. It may be necessary to do them more frequently should certain benchmarks negatively change. For example, are operating expenses increasing at faster rate than operating revenues? Is your medical cost ratio increasing or exceeding the benchmark for your size organization? Are you considering a new information system? An operational assessment will help identify opportunities to streamline processes and identify features that will be needed in the new IT system. In the end, you will make a better IT system selection that meets your needs.

If an organization is considering changes to its reporting relationships and internal processes, an assessment can provide an important roadmap that will lead to better decision-making.

What Is In An Assessment?

A comprehensive assessment should examine 12 areas. Each area is deserving of assessment. But assessing all 12 areas allows one to integrate the impact one area has upon another. A description of the 12 key areas are provided below:

Claims Administration: Are claims processed accurately and timely? Is authorization rapid and effective? What is the, adjudication process? Are claims processed electronically?

Executive Leadership: What is the strategic plan? Is performance managed? Is there a functional organization structure with a customer focus?

Financial Management: Is there a functional budget? Are there sufficient accounting resources? Are management reports useful? Is IBNR managed? Is there stop-loss coverage? Is premium billing & collections efficient? Are there COB issues?

HCFA and Regulatory Compliance: Is the plan compliant with HCFA requirements? The State's Department of Insurance? What are the plans for HIPPA? Are there reserve requirement issues?

Information Systems: Are there too many systems that don't integrate? What systems would improve operations? Is outsourcing a consideration? Are there decision management tools? What are the Internet strategies?

Marketing & Sales: Is there a plan? How are sales managed? Are customer needs met? Are broker relations managed? Is there adequate sales support?

Medical Resource Management: Is the Utilization Management program up-to-date & comprehensive? Is there a current Quality Management Plan? Are there adequate resources for referral & case management, concurrent review, discharge planning? Are you profiling providers? Managing population?

Member Services: Are members satisfied? Is enrollment efficient and accurate? What are the education & problem resolution programs? Is the appeals/grievance process effective?

Network Development: Are providers actively managed? What are the reimbursement strategies and incentive programs? Is there an active recruitment plan?

Provider Relations: Are there education programs? Is there a problem resolution mechanism? Are provider needs assessed?

Quality Management: What is NCQA status? Reporting HEDIS data? Are there clinical pathways & patient profiling? Is there a risk management process? Is recredentialing process efficient?

Underwriting: What methods are being used (risk versus experience analysis)? Are they involved in pricing, and product development?

In the coming issues, we will describe components and how they can be used to improve performance.

Share Your Experiences

Are you willing to share your experience in conducting Operational Assessments? If you are, write your story and email it to info@mcres.com. We will combine all submissions in a format that we can publish, while keeping the information about you and your organization confidential. Your stories will help paint a picture of how assessments are used by others. Again, all information provided to MCR will be kept strictly confidential. Thank you in advance for your participation.

Managed Care Resources, Inc. Newsletter June 2001 Volume 1, Issue 1
Get to Know Us - Ira Rosenberg -- Operational Assessment
Is Your Web Site Ready for Accreditation? -- Canada's Medicare System

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