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  • Fraud, Waste & Abuse: HCL's Intelligent Rule Based Solution

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    HCL Technologies
    20 vues10 pages
    As health care costs keep escalating, the potential for fraud, waste, and abuse does, too. The White House has reported total recoveries over the past three years (ending in 2011) to the tune of $10.7 billion. Also, the number of individuals charged with fraud rose from 821 in fiscal year 2008 to 1,430 in fiscal year 2011 – a nearly 75% increase. HCL has developed a fraud, waste and abuse management framework, enabling customers to benefit from either the full power of an End-to-End framework or a point solution that caters to specific issues. HCL’s Fraud, Waste & Abuse (FWA) Management Solution offers services supported by analytical tools that helps the Payer/PBM handle the issue of increasing healthcare fraud, waste and abuse. Leverage HCL’s intelligent rule based FWA solution to proactively identify potential fraud cases, wasteful and abusive billing practices and avoiding pay and chase scenarios. To learn more, please visit: http://microsite.hcltech.com/gainwithchange/FWA.asp

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    Fraud, Waste & Abuse : HCL’s Intelligent Rule Based Solution

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    As health care costs keep escalating, the potential for fraud, waste, and abuse does, too. The White House has reported total recoveries over the past three years (ending in 2011) to the tune of $10.7 billion. Also, the number of individuals charged with fraud rose from 821 in fiscal year 2008 to 1,430 in fiscal year 2011 – a nearly 75% increase. HCL has developed a fraud, waste and abuse management framework, enabling customers to benefit from either the full power of an End-to-End framework or a point solution that caters to specific issues. HCL’s Fraud, Waste & Abuse (FWA) Management Solution offers services supported by analytical tools that helps the Payer/PBM handle the issue of increasing healthcare fraud, waste and abuse. Leverage HCL’s intelligent rule based FWA solution to proactively identify potential fraud cases, wasteful and abusive billing practices and avoiding pay and chase scenarios. To learn more, please visit: http://microsite.hcltech.com/gainwithchange/FWA.asp

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    20 vues10 pages

    Fraud, Waste & Abuse: HCL's Intelligent Rule Based Solution

    Transféré par

    HCL Technologies
    As health care costs keep escalating, the potential for fraud, waste, and abuse does, too. The White House has reported total recoveries over the past three years (ending in 2011) to the tune of $10.7 billion. Also, the number of individuals charged with fraud rose from 821 in fiscal year 2008 to 1,430 in fiscal year 2011 – a nearly 75% increase. HCL has developed a fraud, waste and abuse management framework, enabling customers to benefit from either the full power of an End-to-End framework or a point solution that caters to specific issues. HCL’s Fraud, Waste & Abuse (FWA) Management Solution offers services supported by analytical tools that helps the Payer/PBM handle the issue of increasing healthcare fraud, waste and abuse. Leverage HCL’s intelligent rule based FWA solution to proactively identify potential fraud cases, wasteful and abusive billing practices and avoiding pay and chase scenarios. To learn more, please visit: http://microsite.hcltech.com/gainwithchange/FWA.asp

    Droits d'auteur :

    © All Rights Reserved
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    sur 10

    HCL Healthcare Payer

    Solutions
    Patient Engagement Platform

    Copyright 2014 HCL Technologies Limited | www.hcltech.com

    Healthcare Challenges

    $300 Billion in redundant or ineffective healthcare


    Effective Care Management and Reduced cost of care
    Regulatory Compliance and Reporting
    Consumer Engagement Explosion
    Administrative overheads

    Payer

    $290 billion annual in prescription


    non-adherence
    Proactively managing quality and
    outcomes
    Improving efficiency of care delivery
    Managing Financial Risk and Incentives
    Regulatory Compliance

    Provider

    Pharma

    One in four seniors take between


    10 and 19 pills a day
    1.5 million annual avoidable adverse
    drug events
    Pharma companies are not pushing
    Pills alone anymore, but looking at
    total solutions
    Drug Cost vs. effectiveness;
    Regulatory Compliance and
    Transparency

    Copyright 2014 HCL Technologies Limited | www.hcltech.com

    Payer Member Care


    Management

    HEALTHONE

    Provider Patient
    Engagement

    Make better and informed


    decisions

    Have greater
    responsiveness to Care

    Be more discriminating,
    efficient and effective
    users of healthcare
    resources

    Have a greater
    adherence to health,
    wellness and quality
    guidelines

    Follow best practices

    Copyright 2014 HCL Technologies Limited | www.hcltech.com

    Patient Engagement Life-cycle

    Measure Care Outcomes


    Measure Outcomes based on
    the set benchmarks
    Degree of appropriate use of
    services

    Enable Self Managed Care


    Member Tool kits
    Patient Education
    Self-Managed member tool
    kits to measure and track
    health parameters

    Enable Follow up care through Patient


    Engagement
    Call Scheduling
    Multi-channel patient outreach
    Alerts and Adherence Monitoring
    4

    Member Stratification
    Burden of Illness +
    Utilization based score
    Member Demographic

    Member to Provider Attribution


    Member attribution to PCP
    Analyzing Claim data for Member
    attribution

    Set care delivery goals and


    incentives
    Track Current Costs
    Set benchmarks and targets for
    incentives

    Care Delivery to Member Execute Care Plan


    Care Plan for members with chronic or severe
    disease condition
    Define Key patient problem and provide
    guidelines
    Referral Management

    Copyright 2014 HCL Technologies Limited | www.hcltech.com

    Member Stratification & Attribution

    DATA
    SOURCES

    ANALYTICS
    ENGINE

    MEMBER
    SEGMENTATION

    PCP
    ATTRIBUTION

    Member Stratification and Segmentation based on Burden of Illness score


    Member Attribution to PCP based on Member visits based on frequency and recent visits to a PCP
    Copyright 2014 HCL Technologies Limited | www.hcltech.com

    Care Delivery through Patient Engagement

    Nursing Coordinator

    Online Resources

    SMS/ E-Mail

    Snail Mail

    PCP

    DISEASE BASED
    CARE PLAN

    PATIENT
    ENGAGEMENT

    PATIENTS

    PCP assigns a Patient to a pre-defined Disease Protocol based on the Patients Disease condition, stage and need for a
    Care Plan
    Patient is supported by a Care Plan administered through multiple Channels and is provided online resources/ toolkits
    for self-managed care
    Copyright 2014 HCL Technologies Limited | www.hcltech.com

    Setting Care Delivery Goals and


    Measuring Outcomes

    Track Current Costs and set benchmarks


    Measure Outcomes based on the set benchmarks and identify outliers
    Measure degree of appropriate use of services

    Copyright 2014 HCL Technologies Limited | www.hcltech.com

    Patient Engagement Platform

    Enrollment through
    physicians
    Direct enrollment thru
    marketing channels

    PATIENT ENROLLMENT

    Channel

    Therapeutic
    Area
    Counselor
    Pool

    Program benefits to
    patients
    Biological behavior
    mapping with disease
    symptoms and patient
    support program
    correlation

    PATIENT PROFILING &


    SEGMENTATION

    O/ B Calls

    SMS

    How much
    knowledge
    disease &
    treatment
    How concerned
    about the disease
    Perceived control
    of their health

    PATIENT COUNSELING

    E-Mail/ Snail-Mail

    Reminder calls
    scheduling
    Education on ongoing
    treatment
    Gather adherence
    data points

    ONGOING CARE

    Online Resources

    Diabetes, Asthma, Rheumatoid Arthritis, Osteoarthritis, COPD

    Nurses

    Pharmacologist

    Life Science Graduate

    Dietician

    PEP PLATFORM
    8

    Copyright 2014 HCL Technologies Limited | www.hcltech.com

    For Questions,
    Please Contact: contact.lsh@hcl.com

    Copyright 2014 HCL Technologies Limited | www.hcltech.com

    10

    Copyright 2014 HCL Technologies Limited | www.hcltech.com

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