Through the acquisition of Healthcare Technology Management Services (HTMS) in March 2010, Emdeon now offers consulting services to help payers innovate, solve problems and optimize performance in an ever-changing healthcare environment. Acting as a strategic partner, HTMS, an Emdeon Company, helps healthcare clients develop and implement technology solutions to align with healthcare trends and each client's overall business strategy. HTMS empowers payers to achieve technology-enabled transformations.
Mike Comick, HTMS co-founder, explains what makes HTMS unique and shares the company’s focus for 2011 in this question-and-answer session.
Q. How did HTMS get started and what was your vision for the company?
A. Mike Weiher and I started HTMS in 2000– each of us has more than 25 years’ experience as healthcare consultants. Through the years, we have seen demands for healthcare consulting change. In response, we wanted to create a company that offers productive, experienced staff with specific skill sets and expertise that work variable lengths of engagement to meet particular client requirements. Our strategic approach includes reality-based interventions with practical solutions and measurable outcomes.
Q. You two are healthcare veterans! How does HTMS differ from other consulting companies?
A. We reduce the risk inherent to consulting by getting the people a payer really needs to do the job. We make sure our consultants have the specific expertise a payer wants and are engaged only at certain times, when the payer needs them. This helps us keep roles competitive and minimizes excess costs.
Another thing that makes us different is our employee model. We have 80-110 people in the field…a 40/60 ratio of employees to contractors. Our consultants have deep health industry knowledge. They have experienced a lot of the challenges organizations face, so they understand that payers may have limited time and resources, out-of-date systems, antiquated processes and diverse perspectives.
Q. Targeted staffing and optimal efficiency must be especially popular with payers these days. Which successes make you especially proud?
A. We focus on healthcare technology and operations at the executive level. As numerous regulatory and market‐driven healthcare IT changes converge, payers have to assess their existing platforms and respond to these changes. HTMS specializes in researching and assessing the healthcare IT software and service vendor market for “best-of-breed” solutions. Our leadership team has a unique blend of experience, including senior executives from healthcare organizations and leading market research firms.
Key Focus Areas Include:
• Core claims and administrative systems
• Care management
• Automated member acquisition
• Healthcare reform
-5010
-ICD-10
-MLR
-Meaningful Use
-Health Benefit Exchange
Q. Those are all very important topics for payers. How do you typically engage a payer client?
A. Our goal is to determine what the client wants– to peel the onion, so to speak. We consider education and market awareness to evaluate how a particular payer compares to its peers, and establish what it would take for the payer to compete with its leading competitors. Then we assess whether the client is willing or able to commit resources– financial, system and time- or if they can procure what’s needed to reach the top in that market. Once we’ve determined that, we analyze the payer’s strategic plan and identify gaps. Afterward, we implement and execute, testing all the systems and applying industry best practices.
Q. How do you evaluate a payer’s peers?
A. Each month HTMS distributes a survey with 8-15 questions about critical issues plans face today. The responses we receive provide benchmarking information and help us assess how payers are faring in a certain area, such as ICD-10 preparedness. Once we aggregate the data, we create a summary of our findings, which we share in a knowledge brief. We send a link to these online results when we survey payers about the next month’s topic. HTMS has conducted the surveys for years and has gained valuable insight and perspective into the payer market. We look forward to expanding the surveys and building our recipient list.
Previous surveys covered topics such as:
• Program management and organizational prioritization
• ICD-10 readiness among health plans
• Health plans struggling with 5010 compliance
Q. The survey feedback sounds especially useful. But, are there privacy concerns?
A. No. Survey responses and results are shared, but no proprietary information or identifying characteristics are given. The information gleaned from these surveys is NOT used for sales, but rather to give HTMS better insight into the payer marketplace. Interested in participating in the HTMS Executive Survey program? Email research@htms.com and request to be included in our next survey.
Q. That will likely reassure our readers. How will HTMS help payers respond to recent legislative changes in healthcare?
A. In light of ongoing healthcare reform, regulatory changes and the consumerism trend, payers need help assessing their current IT strategies– now more than ever. The HTMS team provides strategic support of technical remediation, such as the transition to the new version 5010 and pharmacy D.0 transaction formats, through the delivery of education and training workshops. For example, HTMS can help clients identify the impact of changes to workflow, systems, coding and clinical guidelines they will face in the transition to new ICD-10 code sets.
Q. ICD-10 impact is at the top of many payers’ concerns. What’s one area you’re passionate about personally?
A. While my coworkers at HTMS recognize me for my healthcare expertise, I also get a lot of attention for my love of the New England Patriots. With HTMS based in Indianapolis, Indiana, home to the Indianapolis Colts, my choice of teams baffles a lot of my Colts-leaning coworkers. They do, however, enjoy debating the topic with me during football season—or just about any time!
Q. Well, that can certainly divide an office! What’s your primary focus for 2011?
A. The Patriots starting the season off strong! Oh, you mean at HTMS? The evolution of healthcare reform and its subsequent implications for payers. We’ll start by evaluating a payer’s IT portfolio management systems to determine whether their technology and/or internal systems meet new and future requirements. Then, we’ll establish remediation and system replacement and, if applicable, recommend system and organizational investments.
We plan to pay special attention to:
• Commercial plans
• Traditional Medicaid-only plans
• Specific healthcare reform issues in CA and MA
For more information about HTMS, an Emdeon company, including survey results and white papers, visit www.HTMS.com.
Michael Comick, Partner
As principal and co-founder of HTMS, Mike Comick leads HTMS' business development initiatives and industry intelligence and analytics practice while directing automated member acquisition and care management service offerings. He focuses on strategic consulting services, including IT and business planning, system assessments and procurements, and implementation services. Previously, Mr. Comick was a vice president with First Consulting Group's Los Angeles office, specializing in core claims and administration software applications. He joined FCG after working with Charles J. Singer and Co./Gartner Group as the practice leader for core system market research. In that capacity, he published the ‘Managed Care System Vendor Guides,’ the ‘Managed Care System Win/Loss Analysis’ and the ‘HMO MIS Budget Report,’ a comparative analysis of the leading managed care systems in the industry today. Using this analysis, Mr. Comick facilitated numerous workshops and education sessions with both the payer and at-risk provider markets. He has a degree in economics. When he’s not working, Mike collects and wears a lot of Hawaiian shirts—and enjoys greeting colleagues with an enthusiastic, pirate-style “Arrrrrgggghhh!”, a tradition that began at a company meeting several years ago and remains today.
An Inside Look at HTMS, Emdeon's Newest Payer Solution Offering
ICD-10: Moving Beyond Compliance to Leading Edge Innovation
by Benjamin Heck, MHA
“This massive effort …calls for all healthcare stakeholders to completely rework operations for claims processing, provider contracting, medical management, quality reporting, information technology, disease management and other business and healthcare activities. ”
—Karen Ignani, President and CEO, AHIP www.AHIP.org
ICD-10 implementation may be one of the biggest challenges payers will face in the next five years. Though often seen as a compliance issue, ICD-10 offers a new way of doing business for those who embrace and plan for the change, instead of just responding to it. Given its wide-ranging impact on multiple payer departments and supporting technology, planning a strategic approach to imminent ICD-10 requirements is critical.
To develop this approach and gain a competitive advantage, payers must first:
• Understand ICD-10’s impact on virtually all payer information systems, operations, medical policy, staff, rules and processes
• Realize compliance is not just about programming system changes – it is about re-engineering business processes to harness the clinical detail ICD-10 provides
• Compress timelines and implement new processes quickly, to maximize the power of ICD-10 and ensure a smooth transition
• Communicate closely with provider networks to minimize negative transition effects and maintain goodwill
ICD-10 coding can offer many benefits, including:
• More accurate payment for new procedures. The American Medical Association (AMA) estimates the health insurance industry could save $777.6 million in unnecessary administrative costs by improving claims processing accuracy by just one percent. Role-specific training on the new, expanded code sets and meticulous system configuration that automates claim processing can reap a valuable return. To ensure accurate, consistent communication, payers and their provider networks should examine contracts to capitalize on the more specific codes.
• Fewer fraudulent claims. Implementation of ICD-10 code sets will not eradicate healthcare fraud. However, the specific, granular nature of these codes creates more accurate data, enabling rapid detection of questionable billing patterns and fraudulent claim submissions.
• Fewer rejected claims. Rejected claims cost both providers and health plans significant money. Incomplete documentation and duplicate claims submission cause most claims rejection. Better provider education and more accurate billing will lead to more prompt payment processing.
• Improved disease management. ICD-10 codes can help case managers better identify candidates for disease management programs, thereby improving member health by preventing or delaying serious complications.
• Better coordination of response to disease outbreaks. Through common coding and reporting, healthcare institutions can identify and respond to international disease outbreaks faster and more effectively.
Critical Deadlines:
There is no indication the government will move or relax the following dates. Wishful thinking is not a compliance strategy; strategic planning is the only way to remain competitive.
• January 1, 2012—HIPAA 5010 Compliance. Plans must be able to receive claims electronically using the X12 version 5010 and NCPDP Version D.0 standards.
• October 1, 2013—Plans must comply with ICD-10 rule sets.
Benjamin Heck, MHA
Benjamin Heck has more than 15 years of experience in the healthcare industry, providing IT and health plan operations consulting. He has led, and been involved with many successful core system implementations for a variety of healthcare payer organizations and has experience in information systems, project management, consumer-driven health, business process outsourcing (BPO), Medicare Advantage, ICD-10 and health payer operations. Prior to joining HTMS, he worked as a director of operations for several Mid-West health plans. Mr. Heck currently serves as a partner with HTMS, an Emdeon company, and leads the system assessment, procurement, implementations and ICD-10 practices.
Common Sense and Common Ground Can End Healthcare Gridlock
by Emdeon CEO George Lazenby
In 2011, our country must tackle three serious but potentially conflicting objectives to return to economic health: 1) We must decide the fate of healthcare reform; and, simultaneously, 2) shrink the federal budget deficit; and 3) reduce taxpayers’ burden.
The stakes could not be higher as the 112th Congress debates repealing or modifying the Patient Protection and Affordable Care Act of 2010. Recently, the Congressional Budget Office announced the federal budget deficit for 2011 will be at least $1.5 trillion—a deficit record no one wanted to see broken.
Against this challenging background, it is easy to assume we will be stuck in healthcare gridlock. But I believe there are common sense actions we can take today, with support from across the political spectrum, that can help lead us out of gridlock and get us back on track to being a healthier nation with a brighter economic outlook.
To learn which three steps Lazenby believes could help the U.S. healthcare industry start reversing billions in annual healthcare losses, visit: www.emdeon.com/fraudprevention, and download this article from the Bureau of National Affairs’ Health Care Fraud Report.
Payer-Focused Webinars Can Help You Stay Competitive
Emdeon offers several educational, payer-focused webinars that give you access to industry experts and ideas that are revolutionizing the payer marketplace. Emdeon’s 60-minute webinars are designed to keep you informed, analyze industry trends and share new and innovative approaches to the payer business. Use the information provided to help your organization improve efficiency and maximize profits with these leading-edge webinars.
Available Webinars:
Payment Integrity
• Building Your Payment Integrity Arsenal: Protecting Your Members, Providers and the Bottom Line
Recent healthcare legislation dramatically altered the payer landscape, making fraud, waste and abuse management a top priority. Success in this new environment means adapting to regulations by adopting leading edge technology that is flexible, reusable and meets government requirements, all while optimizing efficiency. An integrated, holistic approach to fraud detection and prevention combines predictive, data-driven analytics with expert analysis and investigation, to help payers meet guidelines, reduce unnecessary payments and improve profitability. This live webinar featuring IDC analyst Janice Young offers insight into a changed healthcare marketplace—one that necessitates another look at powerful new fraud, waste and abuse detection technology.
Access this webinar:
http://www.emdeon.com/contactform/shortform.php?promoCode=PIARSENAL929
• Maximize Savings and Minimize Lost Dollars Using an Integrated, Holistic Approach to Payment Integrity
Learn how to protect your organization from healthcare fraud, waste and abuse using Emdeon Payment Integrity Solutions. Emdeon’s multi-layered fraud-detection system enables accurate identification and investigation of suspect claims both prior to and after claim adjudication and payment. Benefits experienced by shifting from a retrospective, pay-and-chase model to a proactive, preventive paradigm are examined and explored. The session concludes with a question and answer session and discussion around the need for an integrated Payment Integrity methodology.
Access this webinar:
http://www.emdeon.com/support/webinars/2010NHCAA/
ICD-10
• ICD-10: Strategies for Assessing and Addressing Impact
It is critical that healthcare organizations recognize the transition to 5010 and, subsequently, ICD-10 affects virtually all people, processes and technology in an enterprise. In most cases, payers must research and modify all processes/work flows, systems, coding, clinical guidelines and interfaces to comply with ICD-10 standards. Payers must address ICD-10 not only to adhere to HIPAA regulations, but also to remain competitive in the market. This webinar outlines ICD-10 and 5010 implications, offering an assessment strategy that may help payers make these transitions smoothly.
Access this webinar at:
http://www.emdeon.com/contactform/shortform.php?promoCode=WEBINARSAAI
Care Management
• Evolving Care Management Strategies: Patient-Centered Medical Home
The concept of a Patient-Centered Medical Home (PCMH) is hardly a new one –a form of the concept was often practiced a few generations ago. However, as healthcare progressed, approaches changed and the PCMH approach virtually disappeared. With the influx of technology over the last decade and increased pressure to reduce healthcare costs while improving outcomes, a modernized PCMH is one way to improve care management and coordination that is gaining traction.
Access this webinar at:
http://www.emdeon.com/contactform/shortform.php?promoCode=WEBINARECM
• Improving Care Coordination by Utilizing Existing Technology
Improving outcomes and decreasing healthcare costs are two key challenges in healthcare today; enhancing care coordination can help solve both. The severity of the problems demands involvement from stakeholders throughout the healthcare community, and yet the complexity, costs and often resulting inconvenience associated with some technological solutions often leaves stakeholders feeling underserved and overwhelmed.
Access this webinar at:
http://www.emdeon.com/contactform/shortform.php?promoCode=WEBINARICM
• Synchronizing Care Coordination and Pay-for-Performance Initiatives
Health plans, the healthcare provider community and patients can all benefit from the quality improvements and cost reductions involved with tighter patient care coordination. Pay-for-performance initiatives are often designed to incent providers to improve their patients’ health by encouraging adherence to evidence-based guidelines and use of the most appropriate treatments. Linking care coordination to pay-for performance initiatives requires understanding the intended goals and using technology that enables a broad spectrum of healthcare stakeholders to communicate patient information.
Access this webinar at:
http://www.emdeon.com/contactform/shortform.php?promoCode=WEBINARSCM
Increase New Electronic Transaction Utilization!
Have you added a new electronic transaction lately and aren’t seeing ideal utilization levels yet? It may be because your providers’ system vendors have not implemented and turned on the transaction within their systems.
Emdeon now offers you a resource to help improve new transaction utilization with those providers who connect through a system vendor. Our new Payer Transaction Request webpage educates providers on the steps necessary for requesting these new transactions from their vendors. It even offers a letter template that can be downloaded and placed on the providers’ letterhead to be mailed or emailed to their vendor.
Interested? Simply direct your providers to this site: http://www.emdeon.com/payertransactionrequest/ and you’ll be one step closer to increased new transaction utilization!
Interactive Care Management: A Framework for Healthcare Quality and Cost-Containment Initiatives (An Emdeon White Paper)
The Fundamental Problems that can cause Population Health Strategies to Fail
The American healthcare system today is facing a multitude of problems - a number of which are attributed to failed or less than successful population health strategies. Costs are out of control, and the quality of American healthcare has been challenged when compared to several other developed countries. Approaching these problems, health plans rely on a spectrum of tools, including Prevention and Wellness, Disease Management, Case Management and Utilization Management, and more recently, accountable care organizations, patient-centered medical homes, and pay-for-performance initiatives. These initiatives attempt to reduce short-term and long-term costs while improving the healthcare delivery process and outcomes. Each of these strategies relies on healthcare stakeholders, such as doctors and health plans, exchanging and analyzing information that prompts different actions by physicians and patients. Furthermore, the effectiveness of the strategies is often subject to meaningful adoption and utilization by healthcare providers and the openness of patients to participation and behavior change. Although each of these programs can work in tandem to improve quality and tackle cost challenges, total population health strategies often fail to be as effective as they could be in part because they are not tied together in a new conceptual framework called Interactive Care Management.
To learn more about Interactive Care Management, read the rest of the Emdeon white paper at: http://www.emdeon.com/resourcepdfs/Moving_Forward_with_Reform_WhitePaper.pdf
Moving Forward with Reform: The Health Plan Agenda for 2011 and Beyond
It has been nearly a year since health reform has passed, yet health plans are still trying to keep up with the specific provisions of the health reform law and how they will be clarified in the future. Managed Care Executive Group, Health Dialog and HTMS, an Emdeon company, jointly issued a new report that examines critical issues, priorities and challenges for regional health plans in the post-reform era. The report, entitled,“Moving Forward with Reform: The Health Plan Agenda for 2011 and Beyond” is based on information gathered from a survey of more than 55 health plans.
The report captures several concerns of regional health plans and offers insights into actions that may help health plans address these concerns. The survey provides a mid-term check-in on how the MCEG’s annual Top 10 List of Issues for health plans remains relevant.
To download a copy of, “Moving Forward with Reform: The Health Plan Agenda for 2011 and Beyond,” please visit www.healthdialog.com/go/MCEG.
