Beyond basics: Looking ahead at cap systems
Not just for the big guys anymore
Practices not already involved in capitation but that hope to be in the future are in an ideal position to begin establishing report mechanisms that capitation requires. They can already use these skills in attracting insurers and patients.
That’s the recommendation of Pamela Waymack, managing director of Phoenix Servi ces Managed Care Consulting in Evanston, IL. For physician groups now involved in capitation, several useful capabilities are available if you want to expand your expertise. These are now available in much more customized formats for smaller practice settings.
Here are examples:
• Patient report cards. Even if you’re not capitated yet, automating this process can go a long way toward getting you up to date in the market and prepared for more sophisticated managed care arrangements.
• Demand management. These systems were first developed for large hospitals and managed care organizations as a way to refer patients more efficiently. Now, they are being applied on smaller scales and are helpful to some physician organizations — particularly those dealing with capitation and that need to provide a wide range of patient care within a specific panel of doctors, Waymack says.
These applications also can provide after-hours clinical advice and triage, physician referral, and medical advice. A new feature also includes an instant "fax service," which provides a library of patient information that can readily be delivered to patients by phone or through the mail.
• Claims auditing software. These systems not only automate the process of checking claims for accuracy and appropriate payment; they also bring more powerful tools into the auditing process. Many offices still use staff personnel to perform audits, but technology increasingly is believed to make the process pay off better. These systems can readily screen for a wide variety of inappropriate billing patterns. They also can more easily audit electronic claims. And, they are equipped to provide consistent checks for unbund ling, upcoding, medically inappropriate or duplicative services, logical errors, and other difficulties. Waymack’s experience suggests that in most cases, these kinds of products pay for themselves by reducing claim overpayments.
Providing protocols for care
• Case management. These systems go beyond the basic tracking of patients among various providers and patient care locations. Case management software offers much more sophisticated automation of case or care management. A key piece is to provide the clinical protocols that strengthen patient care from one setting to another. Case management software also targets cases for disease management and prevention programs, maintains ongoing patient tracking, and supports a variety of outcomes reporting. Case management software can be an invaluable tool for nurse reviewers because it can incorporate clinical guidelines and protocols to ensure the use of consistent criteria in both inpatient and outpatient referrals, she points out.
• Credentialing. Organizations with several hundred providers or more are finding they can’t support the manual effort required to request and then authenticate all of a provider’s training and performance. Software systems can at least automate some of the basic information: tracking down demographic data; initiating the credentialing process; identifying providers ready for recredentialing; and automating correspondence needed for both providers and their affiliated institutions, Waymack says. Beyond that, more sophisticated systems can integrate reference checks into the National Practitioner Database. Also, some can record office visit and chart review information required by the National Committee for Quality Assurance (NCQA).
• Decision support. This is the kind of software that goes beyond basic operations and instead moves a practice toward learning and innovation. Most core capitation systems have reporting methods and tools, but they lack the flexibility, ease, and sophistication of separate decision support applications, Waymack points out. In general, decision support typically offers you lots of different ways of looking at the world; it enables the user to apply his or her own creativity and thought processes to any given scenario to help create new ideas and paths to take.
Some software can handle HEDIS data
These systems typically offer superior ability to perform such tasks as ad hoc reporting, data analysis, and graphic representation of that analysis. They offer many different ways of presenting information and many ways to monitor, query, analyze, and report on multiple key measures such as cost, utilization, resource consumption, and financial performance. Some applications can provide for reporting of the Health Plan Employer Data and Information Set (HEDIS) data, and some also integrate provider profiling and risk adjustment tasks.
• Provider and/or practice profiling. Most physicians are quite familiar with this kind of reporting on their activities via insurers. Now, the same technology is available to practices for internal use, which might help fend off similar reporting issues from external sources, such as payers. These programs analyze referral patterns, costs, utilization, profitability, and resource consumption in just about any way you want to slice it — by individual physician, specialty, clinic, risk group, total network or IPA, etc. The systems are geared to evaluate clinical appropriateness, frequency, and intensity of professional services via statistical comparisons, Waymack says. They are designed to help identify inappropriate and/or unnecessary patient care, adjustment of risk in capitation arrangements, evaluation of choices needed in making physician selection decisions, and generation of HEDIS measures by provider. They also can help you negotiate with payers in showing your patient care effectiveness.
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