eConsult Requirements for Health Plans John D. Nowacek Web Business Development Manager Optima Health Virginia Beach, VA June 28, 2005

Sentara Healthcare Sentara Hospitals Sentara Health Plans Sentara Life Care Sentara Home Care Sentara Medical Group Optima Health Optima Health is a division of Sentara Healthcare, a nationally recognized Integrated Delivery System –Sentara Healthcare ranked by Modern Healthcare in the top 10 integrated networks in the United States for six consecutive years

Optima Health Our mission is to create opportunities for our members to achieve their optimum state of health. Region’s first Managed Care Plan 320,000+ Members “Excellent” accreditation from NCQA on all commercial health plans for the past six years Received Weiss rating of “A-” Members surveyed by Virginia Health Information ranked Optima Health the highest among leading health plans in Virginia* –84% reported receiving the care they needed –77.7% was the Virginia average *reported in The Virginian Pilot, Jan. 25, 2005

Why eConsults? Cost control Obvious trend Leadership goal Potential first to market opportunity Leverage IDN model Information Rx, DM support

Defining eConsult Requirements Market analysis –Best practices –Market leaders –Independent thinking/goals Cross functional team –Multiple customers, multiple “sells” Documentation

Practical, Rational Parameters Budget, Cost PMPM Potential ROI –Marketing value greater than pure ROI in the short term Implementation effort and timeline Enterprise context –VIP strategy, SSO, External Users

eConsult Success Criteria Financial measures Member satisfaction Utilization impact Employer benefit Provider satisfaction, adoption

eConsult Requirements Medical Financial Operational Legal Technical

Medical Requirements Appropriateness of eConsult is at the discretion of the provider Guided, dynamic, condition-specific questionnaires to streamline communication CPT code requirements enforced, tracked Non-urgent conditions, existing patients only

Financial Requirements Reimbursement rate reflects greater efficiency Payment method for copay collected when submitted, billed at completion (no follow-up) Billed at the discretion of the provider –No online charge for eConsult that converts to an office visit

Operational Requirements Processed like any other claim –Set up CPT code Identity/role of responder always indicated to member/patient Performance requirements –Message turnaround time, Patient/member satisfaction Fraud and abuse, audit

Legal Requirements Impact to existing policies and procedures Existing physician contracts Liability and risk management –Professional Liability/Medical Malpractice Where does the care occur? Liability caps, jurisdiction, standards of care –Licensure

Technical Requirements Security Workflow Tracking, History SSO Usability Long-term interoperability

Where are we now? Plan to pilot, learn –Critical mass is a challenge Decide where the value is Aim for long-term viability, growth