Charles Kineke, AVP, BCBSRIJohn Krupar, Managing Director, LM+Co

May 2011

The purpose of the Admin Efficiency work group is to make it easy to work together, with our resources are focused on the goals of affordable, high‐quality health care, versus avoidable administrivia

What will success look like?Our joint admin processes will be reliable, secure and fast

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How BCBSRI communicates with Hospitals

High‐Level Topics

– Coordination of Benefits

– Adjustments

– Case Management/Utilization Review

– Authorizations 

Topic Perspectives

Opportunity Charters

Action Plans

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Hospitals are largest source of adjustment requests

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How our two organizations communicated claim/contracting issues…

Mary Smith

Helen Syl

Patty Leaf

Laura Sense

Lisa Finnbar

Sue Lond 

Genny Manks

Di Mac

Chris Pumis

Cindy Barbie

Sarah DiFay

Janet Fica

Ellen Cook

Larry Goss

Deb Cotter

Charley McMan

BCBSRI & Dell Hospitals

Lisa Piano

Bluecard

CM Issues Log for BC/CHiP

BC/CHiP Issues Log

CHiP + NEMCI

Ops Log Contracting Issues

Bluecard over $50K

Hospital/BCBSRI CI RAIL

Dick Never

Roger Ball

Dee Peterson

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Future State: How our two organizations will communicate claim/contracting issues…

Claims Processing Admin Services

ContractingContracting

Hospital/BCBSRIClaims Issues

Hospital/BCBSRIContracting Issues

BCBSRI & Dell Hospitals

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BCBSRI ViewUnnecessary claim expenses: paying as primary when we should be paying as secondary

Lack of accurate and reliable other insurance coverage information– We do not do a good job at proactively 

gathering COB information from our members, providers and facilities

Hospital’s ViewBCBSRI identifies secondary insurance as primary, but doesn’t identify the insurance and the hospitals  have only BCBSRI on file. (Hospital sources state patient only has one insurance)

Primary vs. secondary files aren’t consistently followed by BCBSRI

Due to timing issue updating eligibility files at time of registration, hospital confirms patient has BCBSRI but claim will later deny for not meeting eligibility and authorization

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Topic:  Coordination of Benefits

Scope:  BCBSRI members treated at hospital facilities

Opportunity: By combining efforts and leveraging information, BCBSRI and RI hospitals can improve the identification and ongoing maintenance of patient coverage

Benefits: • Reduced unnecessary claims expenses• Consistent and accurate claims processing

Action Responsible

Held COB Kaizen Event at BCBSRI. Incorporated feedback from Hospitals 

Note: Names intentionally removed from presentation

Look into whether or not temporary med not is reflected on web

Determine if suspense codes for particular dependent services trigger numerous COB questionnaires

Hospital suggests that BCBSRI follows up with employer HR departments to require other coverage information. Pitch idea at Kaizen event

Hospital  offers to distribute BCBSRI COB questionnaire to patients at registration and forward info.  Present idea at Kaizen event

Research the hypothesis that the change of the BCBSRI website in 2009 increased “no other coverage found” information.  Follow examples that Hospital provided indicating claims BCBSRI denied for other coverage while the web showed “no other coverage”

Research process of requesting and transmitting eligibility information (files 277 and 276) electronically via EDI

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BCBSRIAll Adjustments require manual intervention (rework)

We adjust 35% of Inpatient claims (compared to 5% of professional claims)

We do not have a specific timeframe/cutoff for adjustment request

HospitalBCBSRI accepts electronic claim adjustment but then drops the claim to paper. (This should also be electronic)

This process causes delays and inaccuracies. – IP to Observation– Refund process (audits)– Contract Management system still 

identifies incorrect payments

Clinical audits at Hospitals cause rebill/adjustments

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Topic:  AdjustmentsScope:  Claims for BCBSRI members treated at RI hospitals

Opportunity: By combining efforts, BCBSRI and RI hospitals can reduce delays and inaccuracies in processing claims submitted to BCBSRI, thus reducing adjustments and associated administrative costs. Hospitals and BCBSRI can reduce the number of adjustments by paying correctly the first time and automating the process as much as possible

Benefits: • Reduce claims expenses due to manual efforts• Improve the claims information database on both sides for timely  analysis

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Claim Adjustment and Contract Management Issues

Hospital submits claim 

BCBSRI receives and processes claim

Hospital receives 

settlement (835)

Hospital audits claims

Hospital submits claim adjustments 

on spreadsheets 

BCBSRI receives 

adjustmentsvia 

spreadsheets 

• Out of area / NEHP claims• Chemo drug / clinic claims• Kidney transplants• etc….

BCBSRI works spreadsheets and adjusts 

claims 

Process perpetuates itself….

Current state process for claim adjustments…

Future state process for claim adjustments…

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BCBSRI receives and processes claim

Hospital receives 

settlement (835)

Hospital audits claims

Hospital submits claim adjustments 

on spreadsheets 

BCBSRI proactively 

identifies pain point 

adjustments

BCBSRI adjusts claims  one week out from hospital settlement

Hospital submits claim 

Claim Adjustment and Contract Management Issues

New claim extract reports pulled weekly and proactively worked using existing resources…

New claim extract reports provides detailed claim information and be automatically emailed to responsible BCBSRI or Dell party weekly. Reports in the works include:• Chemo/Clinic claims• Out of network / NEHP suspense• Kidney Transplants• S0189 testosterone claims

Hospital sees adjusted 

claim on next settlement

In as much as possible, removed this step and remove hospital from having to initiate claim adjustment requests or populate spreadsheets….

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BCBSRI

UR nurses complete two daily sheets summarizing how we will pay. The claims received from hospitals often do not match what was communicated on those sheets. As a result, claims are not paid and need to be re‐submitted

Hospital

Retro‐review/weekend patients– Contract terms – BCBSRI has 30 days

Post‐care issue – Placement– BCBSRI – contract with nursing home. 

These same nursing homes won’t take patients on weekends

Behavioral patients (Medical vs. Behavioral) Pedi/Adult– Discharge and readmit

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Topic:  Case Management/Utilization Review

Scope:  BCBSRI members treated at RI hospitals

Opportunity: BCBSRI Utilization Review working with hospital Case Managers can add value to the patient flow process and improve customer satisfaction for BCBSRI and RI hospitals.

Benefits: • Provide a quicker, efficient, and safe placement process• Provide patients with options available for post acute• Wellness programs available to BCBSRI members can be identified at discharge

• Reduce LOS and costs for both hospitals and BCBSRI

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BCBSRITiming of web notificationDiscrepancy of admission compared to web notificationMore information on web requests to include discharge information which may improve retro processLate notification of elective admissionsDuplicate notification of admission due to uncertainty of primacy

Hospital’s ViewPatient crossover issue causing problems with authorizations

Stratify what authorizations do we really need– Example: certain Dx

Good performance should be exempt from process – with annual review statistically driven.

BCBSRI review Passport system

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Topic:  Authorizations/Utilization Review

Scope:  BCBSRI members treated at RI hospitals

Opportunity: Reduce significant administrative costs at both sites by identifying ways to reduce the number of authorizations needed through better utilization review methods that are data driven

Benefits: • Reduce administrative costs• Create mutual responsibility to monitor resources ordered• Increase physician satisfaction by reducing their administrative costs

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Teams are diving deeper into the integration issues between Hospital and Payerto breakdown barriers, build trust and eliminate non‐value‐added work

Much good can come of communication between Provider and PayerFresh eyes can ask “The Five Whys” and challenge the Status QuoContinuing dialogue is needed throughout the value chain to understand the administrative impacts of contracting decisions

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Charles KinekeAssistant Vice President

Blue Cross Blue Shield of Rhode Island

Charley Kineke graduated from the United States Naval Academy in 1982 and served 9 years active duty as a Radar Intercept Officer (RIO) flying the F-14 Tomcat (aka if you remember Goose from the movie Topgun back in 1988).

After leaving the Navy he worked as a consultant for KPMG Peat Marwick and Lotus Development then settled in for a 15 year career at Citizens Bank.

During those years he served in different technology roles including leading the company’s Application Development and Customer Contact technology groups. He also was handpicked to lead the deployment of Lean Six Sigma (LSS) as the Citizens Bank’s Executive Champion.

After experiencing his mid life crisis (and the bottom falling out of the financial industry) Charley transitioned into the healthcare industry and now serves as the Executive Champion of Continuous Improvement at Blue Cross Blue Shield of Rhode Island.

John G. KruparManaging Director

Loughlin Meghji + Company

25 years of experience in performance improvement in industry and consulting firms, as well as the US Military

His engagements have delivered over $25B in benefits and included strategy, organizational redesign, operations, global sourcing, marketing, shared service development, LEAN operations, LEAN Six Sigma deployment and implementation

John earned a Masters of Science in Management from the Krannert School at Purdue University, and a Bachelor of Science in International Relations from the United States Military Academy. He is a Six Sigma Master Black Belt (MBB)

Karen GarzaManaging Director

Loughlin Meghji + Company

Karen has 14 years of financial services, turnaround/restructuring advisory and investment banking experience

She has experience advising companies in complex business sectors, including: healthcare, commercial and residential real estate, and financial services

Additionally she has lead and implement six sigma programs for clients and partnered with GE Credit to launch LSS programs at their client companies. Karen is Lean Six Sigma trained through the University of Villanova.

Karen earned her MBA from the University of Chicago Graduate School of Business, and received a Bachelor of Arts in International Economics, Political Science & Hispanic Studies from Northwestern University

She is a member of the Turnaround Management Association (TMA), the Association of Insolvency and Restructuring Advisors (AIRA) and the Association for Corporate Growth; Karen is fluent in Spanish

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