Medi-Cal's Provider Data: Model for a Statewide Solution?

Transcription

1 Medi-Cal's Provider Data: Model for a Statewide Solution? Linette T Scott, MD, MPH, FACPM Chief Medical Information Officer Deputy Director, Information Management Division Department of Health Care Services April 13,

2 Provider Data in DHCS Provider Application and Validation for Enrollment (PAVE) Managed Care Plan Network Submissions CHHS Open Data Future Phases April 13,

3 PAVE California s Provider Management Module April 13,

4 Fee-For-Service Provider Enrollment Facts 150,000 Enrolled Provider Sites 1,200 to 1,400 Applications per Month 70 Provider Types 26 Different Applications 96 Sub Forms 108 Supporting Document Types External Enrollments 8,400 Transmittals Annually April 13,

5 Screening and Enrollment Comprehensive Digital Workflows Automated Screening Predictive Risk Scoring Provider 360 Research and Analytics Advanced Workflow and Case Management End-to-End Digital Collaboration (Internal and External) Ad-hoc Reporting and Account Management April 13,

6 Monitoring Monthly Database Checks (Federal, State, Boards, etc.) Proactive Alerting (vs. Reactive Reports) Integrated Alert Review and Triage Workflow Advanced Research Tools Automated Learning based on False Positives End-to-End Audit Trail (research/actions) Management and Compliance Reporting April 13,

7 PAVE Architecture: Social Enterprise Technology Modularity Interoperability April 13,

8 Access and Controls Provider April 13,

9 Managed Care Plan Network Submissions April 13,

10 Adopting National Standards X Healthcare Provider Information Maintain provider data bases for claim adjudication, provider directories, patient referrals, and reporting provider information Submit an application to join a provider organization or provider network Verify credentials such as educational/ professional qualifications, licenses, and malpractice coverage/history April 13,

11 Medi-Cal Managed Care Plans Implementation Timeline Plans have been testing since Fall 2016 Plans transitioning to operational transmissions Comparing transmissions with historical methods of transmitting data with goal to retire historical methods April 13,

12 X Data at DHCS Uses Analysis of provider networks and overlap between networks Network adequacy monitoring Support member enrollment and choice through consumer-facing provider directory: OCSP/Providers_and_Plans/Default.aspx Monitor providers through PAVE April 13,

13 CHHS Open Data April 13,

14 California Health and Human Services Agency Open Data Includes data and visualizations from 12 CHHS departments and offices 152k total users since Nov k users in 2016; avg. ~8k/mo 233+ total datasets published chhs.data.ca.gov datanews.chhs.ca.gov April 13,

15 Convert PDF Reports to Open Data Tables Drive Traffic and Expand Program Exposure Source Data Stories CHHS Open Data Being used by CHHS programs, the press, data consumers, and the community Create API-Driven Web Visualizations Create API-Driven Web Apps Match Identifiers and Link Datasets Engage The Public with Code-A-Thon Events Crowdsource Data Hygiene April 13,

16 DHCS on the Open Data Portal: Create API- Driven Web Visualizations gov/dataandstats April 13,

17 Enrolled-Medi-Cal-Fee-for-Service-FFS-P/nnz9-spdi April 13,

18 April 13,

19 Future Phases April 13,

20 Future Phases Adding provider data to the CHHS Open Data Portal Adding providers to PAVE Family PACT Dental Mental Health April 13,

21 Federal Support for Medicaid Information Systems Enhanced federal funds received for PAVE and anticipated for future phases 90% Federal Reimbursement (Design, Development, and Installation 75% Federal Reimbursement (Maintenance and Operations) April 13,

22 April 13,

23 California Health and Human Services Agency Data Playbook Each play contains data strategies, approaches and actions a Department may use to administer programs and address policy issues 1. Define: goals & objectives 2. Assess: tools & capabilities 3. Implement: plan & strategy 4. Evaluate: outcomes & impacts 5. Share: progress & results April 13,