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Published byMeryl Hicks Modified over 8 years ago
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April 22, 2015 Improving the Way California Delivers Health Care Services
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Agenda Medi-Cal Overview Mission Kaizen PAVE MITA Driving Change 2
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Medi-Cal at a Glance 2015/16 Total Budget - $98 billion ($19B state funds) Total Budget - $98 billion ($19B state funds) Beneficiaries served – 12. 1 million Beneficiaries served – 12. 1 million Enrolled providers – 135,000 Enrolled providers – 135,000 Average weekly check-write – $382 million Average weekly check-write – $382 million Average monthly capitation payments - $3.3 billion Average monthly capitation payments - $3.3 billion 71% Managed Care, 29% Fee-For-Service (FFS) 71% Managed Care, 29% Fee-For-Service (FFS) 4
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PED Files 6
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PAVE Business Rules 7
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TANYA HOMMAN, CHIEF PROVIDER ENROLLMENT DIVISION APRIL 22, 2015 PROVIDER APPLICATION AND VALIDATION FOR ENROLLMENT
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Provider Enrollment Facts 140,000 ENROLLED PROVIDERS 1200-1400 APPLICATIONS 70 PROVIDER TYPES 26 DIFFERENT APPLICATIONS 96 SUB FORMS 108 SUPPORTING Document Types EXTERNAL ENROLLMENTS 1200 TRANSMITTALS 90-180 days PAPER/MANUAL 10
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CHALLENGES Significant Effort Incomplete Submissions Long Wait Unknown Status Provider Dissatisfaction Difficult to Oversee Resource Need 11
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Affordable Care Act (ACA) Additional Information Fee Collection Screening Levels Revalidation Monitoring 12
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Target Improvement Measures EnrollmentScreening & Monitoring Application Submission Effort 40% Reduction for New Applications 60% Reduction for Added Locations 80% Reduction for Updates 80% Reduction in RTP Keeping Bad Providers Out Increase detection (for cause denials) 200% increase in data accuracy Total Application Processing Times Avg. 2-4 Weeks (from 12-24 weeks) Updates < 1 week Real-time Status Tracking Monitoring Risk Detect non-eligible, non- compliant providers within 90 days Generate more audits, investigations based Enhanced Provider Tools Linked Data, Documents and Communications Enhanced PED Capabilities Collaboration with Program Integrity Understanding of Provider Affiliations 13
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PORTAL ENROLLMENTSCREENING MONITORING PAVE 14
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PAVE PORTAL AT A GLANCE 15 Social Collaboration Context Based Intelligence Security Account Management Guided Preparation
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HELPFUL TIPS COMMON VISION COMMON LANGUAGE CLOSE COLLABORATION COMMITTED RESOURCES 16
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Linette T Scott, MD, MPH Chief Medical Information Officer, DHCS April 22, 2015 MITA Driving Change
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DHCS Strategic Vision
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DHCS Transforming and Innovating to Achieve its Commitments It begins with the DCHS Strategic Plan: To the Public … To the People We Serve … To our Employees … 19
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Built on the DHCS Quality Strategy 20 DHCS’s Three Linked Goals Improve the health of all Californians Enhance quality, including the patient care experience, in all DHCS programs Reduce the Department’s per capita health care program costs
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DHCS Business Architecture 21 Vision Mission
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Dynamic Workforce Focus on Core Values from our Strategic Plan: Integrity Service Accountability Innovation 22
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23 Comparability – A Maturity Model http://medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Data-and- Systems/Downloads/mitamm.pdf
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As-Is Redundant Business Process Example 24 Provider Enrollment Process
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To-Be Business Process Example Provider Enrollment Process 25
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DHCS Information Architecture 26
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Information Architecture Enterprise Data Strategy Conceptual Data Model Logical Data Model Standards 27
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Conceptual Data Model http://www.dhcs.ca.gov/services/Pages/Conceptual-Data-Model.aspx 28
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29 Supporting Business Process Transformation Advancing Maturity With National Standards & Frameworks
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DHCS Technical Architecture 30
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As-Is Technology Stack (partial list example) 31
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32 Driving Quality … Technology Level 1 Process consists primarily of manual activity to accomplish tasks. Level 3 SMA automates process to full extent possible within state Health Information Exchange (HIE). Level 5 SMA fully automates process nationally to extent possible via Nationwide Health Information Network. MITA Maturity Levels: Connecting to HITECH Business Process Example: Manage Treatment Plans & Outcomes HITECH Act - 2009 Creating the tipping point to transform health care
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Medi-Cal EHR Incentive Payments as of March 2015 33 ELIGIBLE HOSPITALS Adopt/Implement Upgrade 255$377,484,695 Meaningful Use Payments 443$323,147,328 Eligible Professionals Adopt/Implement Upgrade15,133$319,833,797 Meaningful Use Payments 6,467$ 57,039,250 Totals Total EP / EH Payment Count21,600 Total EP / EH Payments Made $1,077,505,071
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Medicare EHR Incentive Payments & Other Information (March 2015) Medicare Eligible Hospitals Meaningful Use Payments 724$914 Million Medicare Eligible Professionals Meaningful Use Payments 40,632$527 Million Medicare Advantage Providers 10,045$307 Million California EPs/EHs Receiving Incentive Payments 66,789 Total Incentive Payments Made$282 Million 34
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Thank you!
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