Published on January 1, 2008
Slide1: Delivering Integrative Healthcare Under Consumer-Driven Health Plans: Using ABC Codes to Improve Care, Claims & Outcomes Second Annual Conference - January 22-24, 2004 Integrative Medicine for Healthcare Organizations Health Forum & InnoVision Communications San Diego, California Integrative Healthcare in Consumer-Driven Health Plans Use ABC Codes to Improve Care, Claims & Outcomes: Rationale for ABC Codes ABC Coding Solutions A Case Study & Take Home Lessons Integrative Healthcare in Consumer-Driven Health Plans Use ABC Codes to Improve Care, Claims & Outcomes Slide3: Identify best practices to ensure more Americans get the right care in the right place at the right time ...at a rational cost. Need for Better Health, Healthcare & Health Policy Decisions Rationale for ABC Codes Unbiased Measurement! Slide4: 4 Rationale for ABC Codes Fill Critical Gaps in the NHII & Older HIPAA Code Sets Slide5: CAM office visits = 629 million PCP office visits = 386 million Source: http://www.medinfo.ufl.edu/cme/grounds/pauly/; Eisenberg,et al, JAMA,Nov11,1998, Vol 280, No 18 Rationale for ABC Codes Support a Consumer-Driven Healthcare Marketplace Slide6: Need for Management Tools to Improve Business Processes in Healthcare Need for Commerce Tools to Support Industry Efficiencies Need for Complete Standards to Support the National Health Information Infrastructure Need to Resolve U.S. Healthcare Challenges: Access, Quality & Costs Need for Research Tools to Identify the Most Cost-Effective Approaches to Care Characterize, Evaluate & Facilitate Care Rationale for ABC Codes Need for Expanded Standards to Support Consumer Demand for Integrative Healthcare Slide7: Rationale for ABC Codes Establish Open & Unbiased Clinical & Administrative Code Sets Conventional physicians have had government-sanctioned codes owned by the American Medical Association. Until ABC codes were authorized under HIPAA, other practitioners lacked adequate codes. Complete coding is essential for controlling healthcare access, quality & costs. Trade association control supports cartel-like behavior. (An analogy illustrates.) Assume an American Food Association (not a Uniform Code Council) controlled bar codes on all food products. Could the AFA unfairly code international food products? Would fewer international food products reach the grocery store shelves? Could the AFA limit competition & largely dictate pricing & consumption? Slide8: ABC Codes describe alternative medicine, nursing & other integrative healthcare practitioners’ interventions. Relative Value Units (RVUs/RBRVS data) establish the financial value of those interventions. Legal Billing Guidelines (with legal scope of practice information) indicate who can legally provide those interventions & under what circumstances in each state. The HealthIntel Database contains these & other data elements & supports health insurance benefit plan design, managed care & provider contracting, utilization & clinical practice management, claims processing, outcomes research & actuarial analyses. It is the only health-related data set that supports cost-effective adjudication of integrative healthcare claims on a per intervention, per practitioner & per state basis. Rationale for ABC Codes Support Cost-Effective Contracting, UM & Claims Adjudication Slide9: (A Cross Section of the HealthIntel Database) Legal? ABC Code Financial Value Hierarchic Description Detailed Description of Intervention Rationale: Support Cost-Effective Contracting, UM & Claims Adjudication Slide10: Rationale for ABC Codes Support Credentialing & Network Development Rationale for ABC CodesCharacterize & Document Integrative Healthcare Practices: Source: http://www.medinfo.ufl.edu/cme/grounds/pauly/; Eisenberg,et al, JAMA,Nov11,1998, Vol 280, No 18 Rationale for ABC Codes Characterize & Document Integrative Healthcare Practices Rationale for ABC CodesImprove Revenues, Reduce Costs & Enhance Brand Equity: Research Conducting outcomes studies Economic, health, quality of life, satisfaction, etc. Management Forecasting demand, managing operations & maintaining medical records (Scheduling patients, optimizing workflow, managing cases, conducting activity-based or standard costing, setting fees/prices, establishing contracts, credentialing, etc. Commerce Conducting manual eligibility determinations, prior authorizations, claims submissions, etc Conducting electronic eligibility determinations, prior authorizations, claims submissions, etc Rationale for ABC Codes Improve Revenues, Reduce Costs & Enhance Brand Equity Slide13: ABC codes were authorized by HHS as a proposed modification to the HIPAA transaction & code set standards. They are HIPAA-compliant for code set registrants & their trading partners. ABC codes support research, management & commerce for alternative medicine, nursing & other integrative healthcare interventions. ABC codes have the exact infrastructure functionality & social benefits that the National Foundation for Women Legislators calls for in the 2003 NFWL “Access to Care” Resolution. Improve Healthcare Decisions, Practices & Outcomes Rationale for ABC Codes Slide14: ABC Codes, Relative Values & Legal Billing Guidelines help justify payment decisions without expensive utilization reviews. Without ABC codes, older HIPAA code sets do not provide sufficient information to verify the legality, necessity & cost-effectiveness of integrative healthcare products & services. Rationale for ABC Codes Ensure Integrative Healthcare Claims Are Not Too Expensive to Process Slide15: ABC Coding Manual for Integrative Healthcare Practitioner Guides to Billable Interventions Using ABC Codes Relative Values for Integrative Healthcare Using ABC Codes Superbills for Integrative Healthcare HealthIntel Database ABC / CPT / HCPCS II Crosswalk CAM Market Report Consulting Services Beta Testing & Co-Development ABC Coding Solutions Consider Resources for Integrative Healthcare Program Implementation Slide16: Competing “Quick & Dirty” Approaches & Their Competitive Vulnerabilities Higher deductibles. A deductible is a total dollar amount that the consumer must pay before the insurer begins making payments for treatments. Under this type of policy, integrative healthcare coverage is offered, but the consumer pays a higher deductible. Policy riders. A rider is an amendment to an insurance policy that may change coverage in some way (such as increasing or decreasing benefits). A consumer may be able to purchase a rider that adds or expands coverage in the area of integrative healthcare. Discounted fee-for-service networks. Some insurers work with a group of integrative healthcare practitioners who agree to offer services to group members at a rate lower than that offered to nonmembers. A consumer pays out of pocket for treatment, but at a discounted rate. Context for the Case Study Create Next Generation “High Value” Integrative Healthcare Programs Slide17: The Holy Grail: Seamless integration to support data collection & drive best practices. Use ABC codes in conjunction with the older HIPAA code sets to support integrative healthcare research, management & commerce. Context for the Case Study Create Next Generation “High Value” Integrative Healthcare Programs Context for the Case StudyImprove Revenues, Cost-Management & the Bottom Line: Reduce the total cost of care by directing MedicarePlus patients with high cost & integrative healthcare-responsive diagnoses through an integrative healthcare program to avoid costly conventional interventions. Expand savings by utilizing the MedicarePlus integrative healthcare model as a prototype for other plans & by targeting high cost diagnoses (associated with both conventional & unconventional interventions) to further reduce the total cost of care. Attract healthier beneficiaries, increase revenues & reduce corresponding medical costs by increasing interest of wellness-oriented populations in integrative healthcare products & programs. Promote a unique brand image & enhance overall market share by extending the most cost-effective integrative healthcare solutions into other plans. Context for the Case Study Improve Revenues, Cost-Management & the Bottom Line Context for the Case StudyShift Coverage & Reimbursement Policies Incrementally : Context for the Case Study Shift Coverage & Reimbursement Policies Incrementally Use qualitative research & actuarial data to identify high cost & high incidence diagnoses responsive to integrative healthcare. Enhance claims adjudication rules engines to accommodate claims that include ABC, CPT, HCPCS II, CDT & NDC. Establish integrative healthcare practitioner contracting & credentialing initiatives. Expand integrative healthcare benefits to targeted ICD-9s & beneficiaries. Compile, analyze & disseminate cost-effectiveness data. Context for the Case StudyLead the Integrative Healthcare Market Preemptively: Support research, management & commerce for integrative healthcare using ABC codes. Identify practitioner type, using special coding modifiers. Establish financial value on a per intervention basis, using RVUs. Establish legal compliance on a per intervention, per practitioner & per state basis, using practitioner guides & legal billing guidelines Support improvements in insurance benefit plan design, managed care & provider contracting, utilization & clinical practice management, claims processing, outcomes research & actuarial analyses on a per intervention, per practitioner & per state basis, using the HealthIntel Database. Help prevent fraud & abuse in integrative healthcare claims. Context for the Case Study Lead the Integrative Healthcare Market Preemptively Case Study: MedicarePlus & Bridges in MedicineAlign Goals of Patients, Practitioners & Payors: Jeffrey S. Sollins, MD Bridges in Medicine (Integrative Healthcare) Ardent Lovelace Sandia Health System (MedicarePlus/Senior Plan) ABC Codes & Best Practices > 5 Years Pioneering Integrative Medicine Program Within Medicare Case Study: MedicarePlus & Bridges in Medicine Align Goals of Patients, Practitioners & Payors Slide22: Clinical Delivery Improved patient-practitioner & practitioner-practitioner relationships Improved understanding of optimal treatment pathways (e.g., equally or more effective, less invasive interventions with lower costs) Improved outcomes, esp. for chronic conditions (e.g., fewer side effects) Administration Constructive inter- & intra-organizational interactions Optimal allocation of organizational resources Financing Improved contracts & revenues Improved operating efficiencies Improved bottom line Case Study: MedicarePlus & Bridges in Medicine Address Clinical Delivery, Administration & Financing Concurrently Slide23: Morris studies the lower right hand corner of the big picture. Case Study: MedicarePlus & Bridges in Medicine Understand We’re at an Early Stage, Dealing with a Global Movement Slide24: We are not human beings having a spiritual experience. We are spiritual beings having a human experience. (Pierre Teilhard de Chardin, 1881-1955) It Is All About Health & Healing Case Study: MedicarePlus & Bridges in Medicine Consider the Context for Care Before the “Enabling Technology” Slide25: Understand the terms holistic, natural, complementary, alternative & integrative medicine. Recognize integrative medicine is not adding a non-conventional modality to conventional Western medicine…mind shift. Learn to build your own bridge. Appreciate strengths & recognize limitations.. Case Study: MedicarePlus & Bridges in Medicine Remember Enabling Technologies Don’t Substitute for Good Thinking & Practice Slide26: * Rachel Naomi Remen, MD HELPING Case Study: MedicarePlus & Bridges in Medicine Remember, In Healthcare, Healthy People are the Product Slide27: Vision vs. Reality Who Benefits from Bridges in Medicine? What Is the Bridges T.E.A.M.? Why Does Bridges Work? How Is Bridges Evolving? Where Are the Remaining Challenges? Case Study: MedicarePlus & Bridges in Medicine Anticipate Significant Shifts from Planned Program Design Slide28: Missed diagnoses…KEN atypical angina Delayed definitive treatment…Cw Diverticulitis vs bladder Ca Unrecognized interactions; anticoagulation…Ginko, feverfew, ginger, vitamin E, garlic & Omega 3 fish oil Contraindications…St. John’s Wort, Cyclosporin, SAM-e & Bipolar Disorder Exploitation...Max the cap Milt Hammerly, MD, Med. Dir., CAM at Centura Health, Denver, Colo., 1998 Case Study: MedicarePlus & Bridges in Medicine Benefit From Lessons Learned Case Study: MedicarePlus & Bridges in MedicineCreate a Win-Win Situation: Patients: Provide patients with knowledge & ability to adopt a proactive approach to their total well being. Deliver healthcare education for more informed decision making. Take a patient-centric approach & use a professional healthcare team. Promote open communication between patient & practitioners in a highly supportive environment. Assure active participation by the patient in his/her own healthcare. Commit to long-term healthcare through a focus on restoring & maintaining good health, wellness education & follow up visits. Case Study: MedicarePlus & Bridges in Medicine Create a Win-Win Situation: Patients Case Study: MedicarePlus & Bridges in MedicineCreate a Win-Win Situation: Practitioners: Give practitioners a mechanism for integrating a care plan. Improve patient records. ID outcomes of care & develop best practice pathways. Prove legality, necessity & cost-effectiveness. Use payors’ language & show what’s in it for them. Reduce contracting, credentialing, coverage, claims management & reimbursement concerns. Focus on the patient. Case Study: MedicarePlus & Bridges in Medicine Create a Win-Win Situation: Practitioners Case Study: MedicarePlus & Bridges in MedicineCreate a Win-Win Situation: Payors: Improve benefit plan design. Streamline contracting. Optimize utilization & care practices. Cost-effectively adjudicate integrative healthcare claims. Conduct outcomes research. Characterize integrative healthcare models, previously not clearly delineated. Collect hard data on care-effective & cost-efficient models useful in managing resource intensive conditions. Support risk management & other actuarial needs. Case Study: MedicarePlus & Bridges in Medicine Create a Win-Win Situation: Payors Slide33: ABC codes, RVUs & legal billing guidelines support research, management & commerce & help stakeholders identify best practices to ensure more Americans get the right care in the right place at the right time ...at a rational cost. Need for Better Health, Healthcare & Health Policy Decisions Conclusion Unbiased Measurement! Slide34: A Tibetan Monk went to a hot dog stand in New York & said, “Make Me One With Everything.” He handed the vendor a $20 bill. The vendor took the $20 but proceeded to turn to the next customer & take his order. After a while, the Monk spoke up & asked for the change. The vendor replied, Slide35: “Change Comes From Within” Slide36: Alternative Link delivers information products & consulting services that help health-promoting organizations & individuals finance, administer & deliver cost-effective care that improves individual & public health, business & industry efficiencies & socioeconomic development. 6121 Indian School Road NE, Suite 131 Albuquerque, NM 87110 USA Tel: 505-875-0001 Fax: 505-875-0002 Email: firstname.lastname@example.org Web Site: www.alternativelink.com Bridges in Medicine integrates conventional & complementary medicine, using a multi-dimensional model, to create balance & wholeness in individuals, caregivers & health plans & the communities in which they live. 3924 Carlisle Blvd. NE Albuquerque, NM 87107 USA Tel: 505-855-5545 Fax: 505-855-5541 Email: email@example.com Web Site: www.bridgesinmedicine.com Ardent Health Services / Lovelace Sandia Health System is a leading healthcare provider in New Mexico. 601 Dr. Martin Luther King Jr. Ave. NE Albuquerque, NM 87102 USA Tel: 505-727-8000 Web Site: www.lovelacesandia.com
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