Provider Data Management: New approaches for solving data quality and facilitating system interoperability

Transcription

1 Provider Data Management: New approaches for solving data quality and facilitating system interoperability Presented by: Dennis Elliott Director Provider Services, TennCare Patrick Aguilar Director, MAXIMUS September 10,

2 Agenda TennCare Background Short-term Business Needs Long-term Business Initiatives Desired Solutions Approach to Technology Acquisition Approach to System Development Solution Components Lessons Learned Current Status 2

3 TennCare Background State-wide Managed Care ü 3 regions ü 2 MCOs in each region ü 2 statewide MCOs Legacy MMIS ü Tightly coupled business functions ü Non-SOA ü Transaction-optimized claims payment model ü Facilities Management Support Contract TennCare Provider Services Responsibilities ü Not Outsourced ü Provider Registration ü Provider Support ü EHR PIPP ü Supplemental financial payment/ receivables ü Managed Care network monitoring MCO Provider Registration ü Must be registered with TennCare ü Eligible to perform services ü Contracted 3

4 Short-Term Business Needs Provider Registration ü Standardize process ü Account for all providers ü Verify required data is collected ü Ensure registration requirements are met Enhance Reporting ü Online view of CAQH data ü Identify data errors ü Online error correction ü Ability to share normalized data with partners Standardize Data Collection ü Increase data quality ü Single process for individuals using CAQH ü Enhanced data validation ü Reduce enrollment time Integrate with the MMIS ü Provide minimum necessary information for x-over claims ü Implement automated interfaces for provider adds and updates ü Pilot web services for integration 4

5 Long-Term Business Initiatives Expand Provider Portal ü Online application (non-individual) ü Online updates ü Provider Services Support Enhanced Automation ü Role-based workflow/queue structure ü Business-based automation ü Integrated reporting mechanisms (dashboards and drill down) ü Network management monitoring ü System configuration vs. development Enhance Interoperability ü SOA integration approach ü Normalized data model ü Multiple interface mechanisms ü Business process integration Meet CORE Requirements ü Make HIPAA transactions available via portal ü Provide secure transport ü Track response times of requests/responses 5

6 Solution to Business Needs Provider Data Collection ü CAQH for individual providers ü On-line self service portal for all other providers ü PDMS as system of record for provider data System Automation ü Single view of provider data ü Business process-based work queues ü Automate other Department functions ü Reporting as part of work process System Interoperability Requirements ü CAQH Registration (roster request) portal (outbound) ü Individual data from CAQH (inbound) ü Provider additions/changes to the MMIS (outbound) ü MMIS provider ID x-reference (inbound) ü Automated NPI/Sanction checking (two-way) CORE Requirements ü EDIFECTS integration ü MMIS integration 6

7 Approach to Technology Acquisition Leverage Active Initiatives ü Maximize reuse ü Maximize enhanced federal funding ü Align with MITA and 7S&C ü Leverage enterprise solutions Phased Development ü Focus on near term pain points ü Plan for multiple phases by provider type ü Align project schedule with other related system releases (MMIS) Expand Web Presence ü All provider types ü All provider interactions Adopt SOA ü Expand web services (internal and external) ü Implement ESB Leverage OIR Infrastructure ü Align with available tools/ technology ü Implement scalable platform 7

8 Approach to System Development Create Standalone Solution ü Leverage EHR PIPP building blocks (web and services) ü Loosely couple functions with MMIS ü Standardized development/db tools ü Open Source utilities Workflow approach to tasks ü Role-based functions ü Automated task management ü Integration across Departments Multi-phase approach ü Implement functional platform (base functions) ü Incremental functionality by provider type ü Iterative development within phase Interoperability ü CAQH ü Web services for MMIS ü WSDL library for data access with partners ü Multiple access models 8

9 System Components Web User Interface ü Internal and external architecture ü Edits as you go/completion tracking ü Document Upload ü Electronic Signature Online Application and Changes ü All data accessible online ü Separation of application/ changes from production data ü Exact view for provider services ü Save and return functions Work Queues ü Configurable work queues by role ü Automated communications tied to work activities ü Performance tracking Support Functions ü Sticky notes ü Auditing ü Communications tracking Reporting ü Online and paper reports ü Dashboards by role 9

10 Lessons Learned External data collection requires data editing Enabling web services with legacy applications is difficult and time consuming System partners have different development approaches Testing requires ample time and focus Trading partners are not all ready to utilize new technology Defining new automation is an iterative undertaking and is best done as phased development System updates and new functions will be required during future development cycles 10

11 Current Status and Plans Phase 1 Individual providers using CAQH as data source Implemented December 2012 Phase 2 Single and multi-specialty groups provider portal, online application December 2013 Phase 2a Electronic remittance advice via portal Early 2014 Phase 3 All other providers types March 2014 Future Work ü CORE Requirements (online access for all HIPAA transactions) ü Additional automation ü Additional data integration/ sharing 11