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groups:healthcare:2018_08_28_payor_notes [2018/08/28 20:11] (current)
Jennifer DeVivo created
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 +Hyperledger Project\\
 +Healthcare Working Group (HCWG) Payor Subgroup Meeting\\
 +August 28, 2018 \\
 +Chat:  ​https://​​​channel/​​healthcare-wg ​ ​(you can use your LFID to login)\\
 +Github: ​ ​https://​​​hyperledger \\
 +Wiki:  https://​ \\
 +HCWG Wiki: https://​​groups/​healthcare/​healthcare-wg \\
 +Public lists: ​ https://​ \\
 +Meetings: ​ https://​​community/​calendar-public-meetings \\
 +Linux Foundation Antitrust reminder: https://​​antitrust-policy ​
 +Chris Cole is a pre auth SME
 +     ​*Works at Care First 9 years - create population health tools
 +     ​*Director in provider application space
 +What’s an authorization?​
 +     ​*Prior authorization - based on some set of rules, or other mandates, laws
 +     *Who submits pre auth? The person who wants to get paid is accountable (hospital itself)\\
 +     *In patient notification - restricted to member is going to be hospitalized,​ skilled nursing, confinement of some kind
 +1. determine whether you need prior auth
 +     *This member needs this service, and now I want to understand if some kind of permission is required
 +2. seeking the requests - put info together, here’s everything about the service i want to provide and is it approved\\
 +3. I submitted request and i want to understand the status of the request\\
 +4. sometimes more records are required based on what you asked to do. Follow on query\\
 +I want to have a knee surgery
 +     *Are all the elements around the member themself - (date of birth, etc.)
 +     ​*Check eligibility - (active coverage? Which product?)
 +     ​*Where is the surgery going to be done? Each setting has unique rules. ​
 +     ​*What?​ Procedure is knee surgery, these certain codes are associated
 +     *Why? Damage or problems, Diagnosis codes
 +     ​*Date/​s?​ How many units during what time period?
 +     ​*Billing provider - ABC surgical assoc is the biller
 +     ​*Rendering doctor - Dr Jones\\
 +We may ask for additional information - particular codes sent in trigger a questionnaire or to upload certain types of records - clinic team to access the request needs additional information
 +     *This entire request is wrapped into one data ball and gets a unique identifier then it’s routed, business rules engine, routed to a reviewer set,general surgical review, work queue and a person is going to apply some clinical judgment on this
 +     *If it’s approved there is generally a clock counting down to the final decision
 +     ​*Approved or denied
 +          *If approved, electronically we notify the asker
 +          *If denied, more rules and regulations
 +          *Right of appeal
 +          *Why was this denied?
 +          *Any other kinds of information about what they can do about the negative decision
 +     *If in authorization I wanted to do knee procedures A and B
 +           *Say yes to one and no to the other - called partial ​
 +           *The no is treated like a denial with right of appeal, etc
 +           *
 +Flag, routine, emergent, emergency\\
 +Behavioral health and emergency requests are turned over very quickly ​ \\
 +As people do their job through the pool, status changes are reflected\\
 +Pain points?\\
 +     *A lot of the things we talked about rely on a person coming to a screen to do part of it. Standardized transactions have more latitude
 +     *A lot to like around making this space more standard, picking up the pace, reducing manual touch points
 +     *A custom set of questions is not supported - non standard is a problem
 +     *What are the scenarios you feel are not standard? If there is an exchange of information on blockchain that eliminate issues?
 +     *Once something is pre approved, how long does it take to get paid? Information is sent to the claim platform in real time. Claim platform is waiting for a claim that matched. Claim comes in, this service matches the authorization,​ claim paid
 +     ​*Outcome - part of your benefit requirement,​ line up at point of payment, if I can’t do that then it’s not a good process
 +     ​*Precision on authorizations is used to predict upcoming expenses
 +     *What percentage are handled manually v automatically?​
 +          *60% based around benefit design, goes through without human intervention
 +          *With the right additional info you could increase that percentage
 +          *If you authorize something 100% of the time, why are you requiring a pre auth? \\
 +Next steps: what areas can blockchain be applied to?
groups/healthcare/2018_08_28_payor_notes.txt · Last modified: 2018/08/28 20:11 by Jennifer DeVivo