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The Health Plan of the Upper Ohio Valley, Inc
The Company
The Health Plan takes pride in maintaining its community, not-for-profit status. While maintaining their focus on community health, they have also been able to diversify and develop new lines of business. This has allowed them to expand their markets while remaining locally managed, which is a benefit to their members. Their business lines include HMO, PPO, POS, Medicare Advantage, WV Medicaid (Mountain Health Trust), VEBA administration, workers’ compensation programs and a variety of TPA services.
The Challenge
The Health Plan Employer Services division’s business segments include two Managed Care Organizations (MCOs) and a Third Party Administrator (TPA). Each of
these business segments needed a claim and medical case management solution that included an Electronic Data Interchange (EDI) module for sending and
receiving injury reports and cost information that met specific state requirements set by Ohio and West Virginia.
The Health Plan initially investigated building a tool internally for claims and medical case management, as well as handling their EDI requirements. After evaluating their options, they determined that internal development would present numerous challenges, including: Lack of Expertise and Support Personnel – Building an all encompassing system for claims and medical case management would take specialized knowledge, programming and lead time. The planning and programming alone would take an extended amount of time to complete. In addition, once complete, the system would require significant IT resources to support the solution. Time to Market – Tracking claims and medical case management by hand is very time consuming. It also requires hours of labor to produce any type of reporting. The Health Plan needed a better solution for claims and medical case management immediately. Keeping up with Regulatory Updates and System Maintenance – Keeping the system updated with the most current state regulations would have required constant monitoring by the management team and coordination with IT staff to integrate modifications into the system on an ongoing basis. Resource Limitations – It would have taken significant resources from The Health Plan’s IT department and other specialized personnel to create a custom program, causing undue hardship on everyone involved. It also would have taken them away from their focus on delivering high quality health care to the community and surrounding area. Cost – Developing a system internally would cost significantly more than the cost of purchasing an existing application, and the ongoing costs to maintain the system would also pose problems.
The Solution
Once a decision was made to look for a third-party solution, the Health Plan explored a number of claims management solutions, but could not seem to find one that could meet all the organization’s needs. At that point, the Health Plan turned to PureSafety’s Prognos™ solution. Prognos™ provided a system that more than met their requirements. After evaluating The Health Plan’s situation, PureSafety recommended that the company utilize its Prognos™ software with its Electronic Data Interchange (EDI) module for managing the organization’s electronic transactions with various state agencies. Prognos™ met the exact requirements to satisfy both Ohio and West Virginia's EDI requirements, and also integrated into The Health Plan's existing medical case management and workers' compensation claim management processes. PureSafety’s Prognos™ software has been used by The Health Plan’s Employer Services division since January 2000. The Employer Services division provides customers with administration and medical management services related to workers’ compensation, disability, and absence claims. And because Prognos™ is an integrated, scalable, and modular solution, it enabled The Health Plan’s Employer Services division to:
In short, Prognos™ became a key building block in fostering growth within the Employer Services division.
The Results
The Health Plan's MCO and TPA has cost effectively maintained superior compliance and performance ratings with Ohio and West Virginia state workers' compensation agencies while promoting an efficient environment for its staff to focus on providing customers with exceptional claim and medical case management services. In particular, Prognos’ EDI capabilities have streamlined The Health Plan’s process of handling the management of electronic transactions to and from state agencies. When data is sent or received, the Prognos™ system is automatically updated and case/claim managers are notified - making communication and data management a totally seamless process. Prognos™ has also provided key information management tools that have enabled The Health Plan to expand its existing business, while addressing many of the challenges the organization faced before implementation, including: Expertise – PureSafety has a permanent staff of experts, who can quickly and efficiently make the changes and troubleshoot any issues that the Health Plan has regarding their claims and case management system. Timely Updates – As state regulations change, the PureSafety staff modifies and updates the Prognos™ software. Resources – PureSafety allows The Health Plan to use their IT resources more effectively. Cost – Using Prognos™ decreases the overall cost of maintaining a claim and medical case management system, while increasing efficiency through a truly integrated solution. |
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