Healthcare IT News - January 2008 - (Page 31) www.HealthcareITNews.com January 2008 ■ Healthcare IT News 31 NEWSBRIEFS DIaBEtES amERIca, INSuRERS paRtNER oN maNagEmENt Diabetes America, Chevron Phillips Chemical Company LP and Aetna have partnered on a project that aims to provide employees with a new diabetes management program. Members or dependents over the age of 18 enrolled in the Chevron Phillips Chemical medical plan are eligible for the program and will be able to use Diabetes America’s services. The program started Jan. 1. Highmark taking bite out of healthcare fraud By PaTTy ENrado, Contributing Editor HumaNa aND RxHuB paRtNER oN E-pREScRIBINg INItIatIvE Humana Inc. is partnering with RxHub to improve patient safety by providing additional information concerning patient care and medication selection to care providers. The initiative will make possible the secure flow of data for limited member eligibility, formulary and medication history to offices that use e-prescribing consistent with the e-prescribing standards. “This method of prescribing medications is an obvious next step for physician offices on the pathway to automation and connectivity,” said William Fleming, a vice president at Humana. BPo supports oregon health plan expansion Benefits include increased customer service, operational efficiency. By PaTTy ENrado, Contributing Editor – Highmark is embarking on its third and final phase of its strategic initiative to combat healthcare fraud. The health plan’s first two phases delivered return on investment through healthcare IT. Highmark’s previous fraud investigations processes were “convoluted” and the special investigations unit was inundated with cases, said Thomas Brennan, director of the unit. After putting together a comprehensive, three-phase PITTSBURGH plan, Brennan’s team worked tool to identify issues Highmark with Highmark’s in-house was unaware of, which were not informatics group to develop identified by FIRST, through the a Web- and rules-based, auto- use of predictive modeling. Taking a year’s worth of mated fraud detection tool called Financial Investigative Highmark’s data, Payment Optimizer ranked the Reporting Systems for payer’s 21,000 providers Tomorrow, or FIRST, and analyzed the top 200 to retrieve and anaproviders. lyze data and generate The application idenactionable reports. tified 44 cases that The second phase, a Highmark was already post-pay retrospective strategy that went live Thomas Brennan working on. “What’s exciting about Fair in September 2007, involved partnering with Fair Isaac to Isaac’s solution is that we deploy its Payment Optimizer fraud see page 33 The Highmark building stands tall above the Pittsburgh skyline. actIvEHEaltH maNagES clINIcal vocaBulaRy ActiveHealth Management, a clinically based, technology-driven health management services company, will expand its medical vocabulary using a language engine technology tool from Health Language Inc. Health Language will provide ActiveHealth with software and services to support recurring updates and management of code sets and medical terminology on a scheduled basis. The technology also will supply ActiveHealth with functionality to deliver consumer terminology content and maps between code sets to support advanced initiatives in care management, CMS medical payment policy edits, P4P, and normalization of disparate databases. cIgNa HEaltHcaRE oFFERS vIRtual HouSE callS Cigna Healthcare will expand a four-state pilot program to provide members with virtual house calls through a partnership with RelayHealth. The calls will be offered to employers with self-insured health plans, offering a more convenient and affordable way to contact physicians for non-urgent, routine health issues. Services will include reimbursable webVisit consultations that use an online, structured interview format to communicate member symptoms to the physician, who can respond online, by phone, or request an in-office visit. More at HealthcareITNews.com e Connect: PaYerS 0108 – Clear Choice Health Plans is expanding its Medicare Advantage, or MA, plans into the western Montana market this month and will introduce new products to Oregon, Idaho and Washington. The health plan, which serves Central and Eastern Oregon and parts of Montana, is looking to business process outsourcing, or BPO, to support these expansions. Adaptis, a BPO provider serving payers, will support benefit, group and claims administration; financial m a n a g e m e n t ; Patricia Gibford quality improvement reporting and analysis processes. BEND, OR The new Clear Choice Health Plans headquarters under construction in Bend, Ore. Patricia Gibford, Clear Choice’s CEO and president, said BPO would help the company serve its customers better, reduce costs as it becomes more efficient and be competitive. The challenge with this implementation was Clear Choice’s legacy system, which had gone through numerous iterations and was not a relational database. “The system is very expensive for what we get out of it,” said Gibford. “A simple change equals a major cost.” With Adaptis BPO system upgrades and maintenance, Clear Choice will be able to learn new ways of doing processes within its system, said Stan Glassman, senior vice president at Adaptis. Jim Anderson, CEO of Adaptis, said the company has built up its project management competency because BPO entails tremendous change in workflow processes. “Part of our methodology is an emphasis on change management,” he said. “We work with organizations and people to introduce change in a very organized, structured way. This is key to making BPO better.” Clear Choice, which serves 12,000 people in its full-risk MA plan, was ranked number one in patient satisfaction by the Centers for Medicare and Medicaid Services in Region 10, which comprises Washington, Oregon and Alaska, and number 15 nationally. Gibford expects BPO to help maintain the regional health plan’s rankings. “We understand rural healthcare,” she said. “Our provider BPo see page 32 NHIN Forum: Data at the heart of HIe sustainability models By PaTTy ENrado, Contributing Editor Estimated annual losses caused by fraud and abuse Healthcare Identity theft Insurance Phishing Credit card $2.8B $1.14B $49B $30B $99B ■ 3-10% of healthcare costs are estimated to be due to fraud and abuse. ● – Sustainable revenue models was an underlying theme at the 4th Nationwide Health Information Network, NHIN, Forum held here last month. During the Q&A at the session, “Population Uses of Health Data,” panelists highlighted ways in which providers and health plans could benefit from the use LONG BEACH, CA of health information technology within the organizations’ health information exchange initiatives. CareSpark, a regional health information organization serving the Central Appalachian Region, has a payer make-up of 25 percent Medicare, 20 percent Medicaid, 18 percent uninsured and 22 percent commercial. NHIN see page 34 ■ Current U.S. healthcare expenditures are in the $2T range, and rising. Fraud losses are expected to rise along as well. ■ The vast majority of abuse goes undetected today. e ● Connect: GraPHS 0108 SouRCe: 2007 FAIR ISAAC CoRPoRATIon http://www.HealthcareITNews.com http://www.healthcareitnews.com/story.cms?id=8426 http://www.healthcareitnews.com/story.cms?id=8427 http://www.healthcareitnews.com/story.cms?id=8428 http://HealthcareITNews.com http://www.healthcareitnews.com/story.cms?id=8429 http://www.healthcareitnews.com/story.cms?id=8433
For optimal viewing of this digital publication, please enable JavaScript and then refresh the page. If you would like to try to load the digital publication without using Flash Player detection, please click here.