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Success Story
MITS provides custom solution for Florida Healthcare Maintenance Organization (HMO).
Company Background
Preferred Medical Plan, Inc. (PMP) is an independently owned, licensed HMO in Southern Florida with 170 employees providing individuals with a range of comprehensive medical, surgical and hospital benefits including dental and optical riders. PMP, Inc. has the largest individual HMO membership in Florida and is committed to providing its members with more choices and benefits than any other individual health plan. In September of 2002, Consumer Reports awarded PMP, Inc. with its highest coverage index for offering the most comprehensive set of benefits.
The Challenge
Due to the nature of their industry, PMP, Inc. has many internal and external information reporting needs. Since healthcare insurance is so highly regulated, they must comply with external state reporting requirements such as enrollment data, HEIDIS, Child Health Check Up and HIV/AIDS statistics, as well as fraud detection and prevention efforts. Internally, there is a need to utilize information to predict and manage expenses, making it feasible to provide the most comprehensive benefits packages possible to members at a reasonable cost. PMP Inc’s Information Services Project Manager, John J. Burns, PMP describes how the company relies on efficient access to data: “From a production point of view, we’re in the claim adjudication business. We need to determine which type of claim or which types of providers are submitting claims requiring the most effort to adjudicate.”
To access their data, PMP, Inc. relied on traditional reporting mechanisms and practices which are heavily dependent on Information Services (IS) resources. John J. Burns provided insight into the common maintenance and development of reports. “Reports that were developed internally by IS staff or canned system reports not customized to our specific needs were run using the same transactional database that was being used in production. There were times when this would severely affect system performance.” This impact on the production system was most evident at the beginning of the month, when most reports are run, and resulted in the production system being brought to a crawl. The drain on the IS resources was also significant due to the amount of time needed to create custom reports or modify existing reports, decreasing the amount of time IS staff had available to devote to other projects.
The Solution
When looking into reporting solutions, PMP, Inc. was concerned about some of the issues associated with maintaining large sets of data in a data warehouse environment. Through his experience with the MultiValue community, Burns was aware of MITS products and the advanced reporting and analytics MITS Discover offered. MITS Discover presented a way to access near real time data without need for a dedicated data warehouse. During further review of MITS Discover Burns realized “[the] Discover hypercube concept eliminated these concerns. We [also] anticipated that the browser-based interface would reduce training time and combined with the ability to export directly into a spreadsheet or Adobe PDF documents would empower the end user and not burden the limited resources of our IS Department.”
PMP, Inc. wanted to find out what types of claims were costing the most to process and who was filing them. Additionally, they needed to perform comparative analysis, such as differences between geographical regions, average cost per claim type and cost per claim by each of their submitting providers. Burns worked with a MITS Product Specialist to design and implement their first set of Hypercubes to provide this analysis.
As a result of past experience, Burns mentioned, “often a solution based on how a product functions is offered or even forced on a client.” He did not find this to be the case with MITS and was impressed with the amount of time the MITS staff took to understand PMP’s business processes and unique needs. He went on to say, “MITS took the time to thoroughly comprehend what we hoped to accomplish and how MITS Discover could meet most of those needs. [The MITS Product Specialist] also clearly stated what the tool was not designed to do, and knowing that actually helped us get exactly what we required out of the design of our Hypercubes.”
The Results
While the rollout of MITS Discover to the majority of PMP’s users is still in process, they are currently using MITS within their Claims, Fraud and Abuse, Utilization, and IS departments. One example of improved access to data is in their Turnaround Hypercube. Claims have a 30 day turnaround for payment and with this Hypercube they are able to identify where outstanding claims stand in their queue. Most claims are adjudicated between day 14 and day 17, resulting in a bell curve distribution of the data. This metric has proved to be so useful that they will be including it, in its graphical form, as a key performance indicator (KPI) on their MITS Discover Dashboard, allowing them to instantly view shifts in the curve and attend to underlying issues.
In its beginning stages the response to MITS within PMP, Inc. has been very positive, with users already providing feedback for additional Hypercubes. Burns followed up on this by commenting, “To me, this is a very encouraging sign. It signals that with very little exposure to the tool, end users are seeing its potential in ways that would benefit them and how it can allow them to produce the analysis and reports that they require.” He has also found that “[MITS] Discover easily uncovers inaccuracies and inconsistencies that can exist in the underlying data, sometimes to the doubt of the user. Verification, however, proves [MITS] Discover to be correct and our assumptions of the data to be wrong. I like to say that if you shine a flashlight in a darkened room and the roaches scurry, don’t blame the flashlight!”
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Company Profile:
Name:
Preferred Medical Plan, Inc.
Distinction:
Licensed HMO provider, boasting the largest individual HMO membership in Florida.
Vertical Software Provider:
DST Systems, Inc.
Database:
IBM UniVerse
Web Site:
www.pmphmo.com
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