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Medicaid Use Cases and Value Statements

Value Statement

Use Case

Development Status and Cost

Potential High Value

Provide Medicaid eligibility at the point of service to verify eligibility, claims history and status, obtain billing information and determine benefit coverage and service limitation.

Use Case:  Providers would be able to log into NeHII and view up to date eligibility information and claims processing status for all patients, eliminating the need to call or utilize other portals, saving Medicaid call volume or support costs.

Use Case: Medicaid personnel would be able to log into NeHII and view other insurance carriers to determine coordinate of benefits.

Add Medicaid Eligibility File to NeHII; flat file sent nightly ($10,000)

Potential High Value

Improve the timeliness, accuracy, quality and completeness of the data received.  Medication History on Medicaid patients will be available through NeHII’s VHR

Use Case:  Medicaid employees would be able to log into the VHR and search for clinical information on their participants.  This information includes lab reports, radiology reports, transcription reports, medication history, problem lists, immunizations, discharge summaries and advanced directives.  Data access must comply with HIPAA and HITECH.

Development needed to filter VHR based on date and matching account level from ADT feed to clinical result.

Account Level Access Enhancement ($90,000), Date Range Enhancement ($40,000),  NeHII Resources costs (PM @ $90/hour; Trainer @ $61/hour, Hours TBD)

Potential High Value

Identify and reduce fraudulent practices and other forms of payment abuse.

Use Case:  Medicaid employees can view the complete medical record for individual participants, with all services, ADT records, and clinical information. Trending of information across the entire population will identify patterns of inappropriate or abusive billing practices enabling focused educational or recovery activities.

Discover Reporting Module- Development planned for 2012

Estimated cost: $300,000 per year for 3,000 physicians.  ($100 per provider per year.

Development of Alert Functionality (TBD)

NeHII Resources costs (PM @ $90/hour; Trainer @ $61/hour, Hours TBD)

Assist in real time claim processing with the development of an All Payers Claims Database to manage eligibility and pull data for all payers from a single source.

Use Case:  Medicaid employees would be able to log into the VHR and search for clinical information on their participants.  This information includes lab reports, radiology reports, transcription reports, medication history, problem lists, immunizations, and advanced directives.  Data access must comply with HIPAA and HITECH.

Annual License Fee s are estimated at $325,000 for Medicaid ($25,000 per year plus $1.50 per member per year)

Improve the ability of Medicaid to assist in the management of care for high cost individuals, especially those with chronic conditions who consume 70% of the resources.  This will help prevent re-hospitalizations resulting from the lack of adequate discharge education, care transition planning, and information exchange.

Use Case:  NeHII will implement disease registry functionality that will be available to all providers to enhance care management of individual participants as they transition across the continuum of care from acute care to post acute care, long term care and home care.  This will improve the quality of care and help to control costs.

Disease Registry Functionality ($100,000 setup per registry, $30,000 per Registry per Year), NeHII Resources costs (PM @ $90/hour; Trainer @ $61/hour, Hours TBD)

Monitor episodes of care and manage coordination of services to ensure services are medically necessary, provided in the appropriate setting, and meet quality standards.

Use Case:  NeHII will implement pre-treatment prior authorizations and utilization review

$100,000 Setup

$0.25 per transaction

Reduce prescription errors which contribute to hospitalizations and rehospitalizations.

Use Case:  Medicaid employees would have access to comprehensive and real-time medication history on all participants and monitor the use of generic drugs when applicable.

Annual License Fee s are estimated at

$325,000 for Medicaid ($25,000 per year plus $1.50 per member per year)

Add Medicaid Prescription Drug information to NeHII.  (TBD)

NeHII Resources costs (PM @ $90/hour; Data Analyst @ $60/hour, Hours TBD)

Improve patient medication compliance with fill notification information.

Use Case:  Medicaid employees would have access to comprehensive and real-time medication history on all participants.

Annual License Fee s are estimated at

$325,000 for Medicaid ($25,000 per year plus $1.50 per member per year)

Reduce the over utilization of lab testing and radiological diagnostic procedures with the availability of test results.

Use Case:  Providers treating Medicaid patients would have the ability to view all clinical information on patients, reducing the number of duplicative tests.

Annual License Fee s are estimated at $325,000 for Medicaid ($25,000 per year plus $1.50 per member per year)

Improve Medicaid provider administration functions, including provider enrollment, licensure verification, provider communications and support other self-service administrative functions

Use Case: Medicaid would have access to state Provider Directory being developed and maintained by NeHII

Annual License Fee s are estimated at

$325,000 for Medicaid ($25,000 per year plus $1.50 per member per year)

Potential payment reform catalyst beyond the standard fee-for-service model

Use Case: Quality Reporting functionality would expand the information available to Medicaid, resulting in new innovations for payment reform.  This functionality would be used to support Patient Centered Medical Home (PCMH) and Accountable Care Organizations (ACO), among others

Discover Reporting Module- Development planned for 2012

Estimated cost: $300,000 per year for 3,000 physicians.  ($100 per provider per year.

NeHII Resources costs (PM @ $90/hour; Trainer @ $61/hour, Hours TBD)

Enhance the ability of the provider to track percentage of Medicaid patients

Use Case: NeHII will allow for real time calculation by providers for the percentage of Medicaid patients they treat for the determination of their qualification for Meaningful Use measures

Included in Discover Report Module

Increase provider compliance with clinical evidence based guidelines and improve the quality of care delivered to all participants

NeHII will implement disease registry functionality that will be available to all providers. The registry will identify gaps in care for individual participants and the overall population allowing focused quality improvement activities.

 

Included in Discover Report Module

Additional Value

  • Improve efficiencies in the Medicaid program through the availability of claims information for eligibility verification, status reporting, filing and payment to providers
  • Avoid redundant state expenditures in building a secondary infrastructure to support Medicaid functionalities
  • Support the State's healthcare providers in achieving Meaningful Use requirements and receiving CMS incentive payments for their efforts
  • Supply the Statewide Provider Directory for the State of Nebraska in support of the NHIN Direct exchange of ePHI
  • Support Medicaid's electronic exchange of information with federal agencies such as DOD, VA, SSA, CMS, ONC, CDC, FDA, and IHS through the activities of the Nw-HIN