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Optimizing Processes in Medicaid Communications Management
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The History of Medicaid
Medicaid is the state-funded program designed to meet the critical medical care requirements of the financially needy, including pregnant women, parents and children, the elderly, and individuals with disabilities.
Since its inception in 1965, has grown significantly. In fact, in 2007 alone, the program provided coverage for 53 million individuals at a cost of approximately *$350 billion*.
With this coverage growth, the complexity of care has increased significantly — beyond in patient coverage.
Today, the majority of benefits are paid to outpatient facilities, hospices, nursing homes, and home health providers.
Today’s Challenges
These recent increases in patient volume, complexity of care, and complexity of benefits present a special challenge to Communications Management — the process of communicating benefits, costs, policies, and directives to beneficiaries, providers, contractors, and other Medicaid constituents.
Medicaid Management Information System
To address growth and complexity, the federal government requires every state to implement the Medicaid Management Information System (MMIS).
MMIS is a mechanized claims processing and information retrieval system, which helps oversee and regulate:
- Administrative costs
- Service to recipients and providers
- Claims and computer operations
- Management reporting for planning and control
MMIS Communication Requirements
One of the primary objectives of MMIS is to support the continued decrease in administrative costs.
For communications management, this decrease is translated into a reduction of labor in producing communications between state agencies, beneficiaries and providers.
Beneficiary Communications
Communications between states and beneficiaries are critical to the success of the administration and the access of quality healthcare for the beneficiary.
Beneficiaries need to know the communications sent to them are timely, accurate, and intelligible. Conversely, beneficiaries need to be able to submit address changes and life status changes to the State as easily as possible.
Effective beneficiary communication, both inbound and outbound, reduces administrative costs and improves member experiences.
Provider Communications
Providers follow a well-defined life cycle in their interaction with Medicaid agencies. They contract to participate in the program, provide care and bill for the care provided.
Most provider communications can be automated since they are triggered by predictable and measurable events, such as:
- Notification of administrative changes in the programs with which they participate
- Notification of the patients assigned to their primary care services
- Receipt of payment, reimbursing them for their services
Communication Challenges
Maintaining correct and up–to–date information has historically been a difficult task for the Medicaid system.
An MMIS system that supports effective communications with beneficiaries must support all aspects of address maintenance and storage including:
- Frequent updates
- Multiple or alternative addresses
- Format validation
- Delivery point determination
Verification & Validation
With the reality of a “black market” for Medicaid identification cards, the system must be highly adaptive and allow the facile re-issuance, validation and verification of beneficiary identities.
Multi-Lingual Capabilities
To be truly effective, all MCM communications also must be delivered in English, Spanish, Vietnamese and Farsi with equal facility.
Geographic Flexibility
Additionally, an effective MMIS system must accurately maintain a physician’s information in their multiple contracted locations and roles.
MITA Standards
Completed in 2003, the Medicaid Information Technology Architecture (MITA) is a standard developed by the Centers for Medicare and Medicaid Services (CMS), an agency within the US DHHS.
MITA is intended to employ industry standards, off–the–shelf software, secure data storage and transmission, and a common “look and feel,” while allowing for the independent use of specific software or hardware.
MITA defines best practices in the areas of:
- Business process definition
- Data management
- Technical architecture
Medicaid Communications Management
Over the last few years, Pitney Bowes Group 1 Software has developed Customer Communication Management (CCM) as a business process concept.
CCM comprises the complete event–to–response sequence of every
customer–to–business–to–customer interaction, often spanning multiple business areas
or departments.
CCM for Medicaid: Medicaid Communications Management
Medicaid’s unique process requirements provide an opportunity to bring the productivity improvement benefits of CCM to the communication processes involved in the administration of these programs, resulting in Medicaid Communications Management.
MCM consists of multiple, interacting solution sets that seek to provide comprehensive management of communications between Medicaid agents.
MITA Business Process Hierarchy Context
In the MITA Business Process Hierarchy (BPH) model, MCM represents a collection of Tier 5 business process groups that meet the communication needs of the Tier 4 or higher business processes.
For many common communication transactions — such as a retiring physician — updates to MITA can be automated and processed by a single administrator in a few minutes.
By utilizing CCM processes for these types of communication transactions, MCM provides both an information service in the sense of MITA definition, as well as a method of managing and reducing communication costs.
Communications Latency Reduction
As the underlying efficiency driver for communications optimization, MCM eliminates information latency from administrative Medicaid business processes.
Reduced retention and latency results in greater information “travel speed,” less effort and benefits to state MMIS operations:
- Increased labor productivity due to the reduction of manual activities (latency) in the preparation, generation and processing of communications
- Specified communications based on constituent preferences without incremental cost or productivity loss
- Supported medical record management
- Superior, best–in–class data quality resulting in improved communications
- Customized communications enabling the efficiency of bulk production while generating unique messages
MCM Business Services
The MCM system itself is comprised of several loosely coupled services that are clustered around data management functions, following the sequence of communications processing:
- Capturing inbound communications
- Storing the content
- Determining the required response or action
- Generating and transmitting the outbound responses
The MCM Business Services consist of:
- Inbound Services: Accepts and indexes inbound, multi-channel communications
- Data Quality Services: Normalizes and corrects a wide range of MMIS relevant data
- Content Management Services: Provides transactional integrity, identification, business intelligence and workflow support to other MMIS systems
- Production Archive Services: Manages the archival of communication data
- Outbound Services: Generates outbound communications based on contextually relevant requests from MMIS business systems
Key Benefits of MCM
MCM supports the many changes made to today’s MMIS business processes. Some of the key process benefits of a modularized communications management system for Medicaid include:
- Closed-loop Communications
- Automated notifications
- Wellness management
Closed-loop Communications
Inbound communications must be related to the proper constituent in a two-step process called indexing, which encompasses up to 12% of the total claims labor.
Closed-Loop communications are intended to eliminate the need for manual indexing, by enabling the communications agent to receive machine-readable context information — for both electronic and print communications.
Automated Notifications
A tremendous amount of effort is spent generating periodic or event-driven communications in legacy systems. MCM reduces this effort with semi-automated transactions, such as:
- Event triggers to monitor authorizations that are nearing expiration, and then providing proactive messages to both beneficiaries and providers
- State agency specific messaging in enrollment and benefit documents to streamline processes.
- Automated messages to all beneficiaries asking them to purchase a generic version upon its availability
Wellness Management
MCM supports large population Wellness Management plans as part of routine transactions, such as:
- Beneficiary birth dates or similar life events can trigger predefined, recommended messages suggesting preventative measures
- State Medicaid agencies can augment their on-line enrollment of new dependents to existing beneficiaries.
Technology Value-Add
MCM in an MMIS system additionally provides technology value-add for Medicaid business processes, including:
- Rules-based transactions and data sharing
- Web-based data access and communications
- Interactive Voice Response Systems (IVRS)
To be successful, every MCM system must be easily adaptable to existing state MMIS technology environments. To achieve this, MCM must be integrated with legacy systems, and existing inbound and outbound communications equipment must be utilized.
Data Management
The MCM Data Management strategy fully embraces the MITA Hub model.
In order to fully benefit from MCM communications competence, MMIS communications must transition from a mainframe-centric implementation to a distributed service-oriented architecture.
MCM features a full complement of CCM-specific Extract-Transform-Load (ETL) capability that can connect to hundreds of structured and non-structured data sources.
Data Quality Services (DQS)
Data Quality is critical to meaningful MMIS operation. Correct information is absolutely essential for effective communication with Medicaid constituents.
- Data Normalization: Services that validate names, addresses, codes, code mappings, telephone number formats and e-mail addresses. Services to normalize data, such as generating unique provider or customer key data, or providing anonymous extracts for HIPAA-compliant review lists.
- Service Code Mapping: Transactional mapping services that provide a bridge solution to map old to new codes for internal operations without immediate re-programming.
- Entity Identification: Services that identify entities embedded in the e-mail text — such as names and addresses — so that communications associates not only reply to the sender, but also include content related to the claim or case.
- Household Identification: Services to determine associations based on address only, or on other data items as determined by state eligibility analysts.
Inbound Message Services
Documents are captured via FTP, HIPAA-compliant EDI, email servers, OCR/scanners, bar code readers and other similar devices.
Inbound images can be stored either in the MCM repository or indexed into an external image management system.
Content Management Services
The MCM content management system:
- Identifies communications content
- Manages content and communication data relationships via the MCM repository
- Provides limited workflow services to partially automate the production of messages
- Exchanges communications-relevant data with existing and legacy systems
- Provides communication intelligence support for DSS
The CMS offers:
- Integrated viewing of 180 document types
- Full text searches
- Sophisticated content search filters with Boolean, wildcard and fuzzy comparison algorithms
- Version control with master and sub-file support to construct visual association of documents
- A wide variety of email management capabilities
- Records management capability to define and execute document and communications retention policies
- Workflow control utilities that support submission, review, approval, routing and notification of communication events
Outbound Message Services
The MCM outbound subsystem provides facilities to efficiently author professional, personalized member correspondence with a system-managed word–processor–like interface.
Composition System
The composition system scales to support thousands of concurrent users, and it also supports remote and distributed access via a customer-care cockpit, an intranet or an external internet.
Features of MCM Composition Services include:
- Creating and controlling of document content by end user departments
- Integrating with MCM repository
- Allowing users to safely and securely assemble, proof, approve and sign-off on documents from any web browser
- Scaling to support workgroups, departments or enterprise-wide users
- Transforming word processing documents or graphic files into interactive templates that prompt end-users for answers.
- Enabling state agency supervisors and analysts to create templates without IT resources
Message Generation
Message Generation consists of converting a document template into an image. Data parameters in the templates are populated with data from the MCM repository.
Message Generation includes:
- Commingling (merging of single prints into a composite) and splitting of print streams
- Inserting two-dimensional barcodes, keyline information, and postnet or four-state barcodes
- Archiving reprints
Production Archive
The Production Archive provides a central repository for the long-term storage of customer communications and other relevant historical information. It is the outbound storage complement of the MCM repository and forms
a central point of collection for all outbound documentation.
The MCM Production Archive services:
- Provide real-time indexing, compression, storage, and retrieval of high-resolution business documents — regardless of age or size
- Provides a high speed, scalable solution — ingesting millions of compressed outbound documents per hour
- Supports high-speed retrieval of documents and high volumes of concurrent users, with no degradation in performance
- Eliminates the need for expensive, high maintenance storage devices
- Satisfies legal and records management requirements for archiving
- Stores and retrieves all print document types and other data
- Includes easy add e-payment option as part of web-based provider or beneficiary services
Online Account Management
The Online Account Management (OAM) suite provides web-based self service and a common invoice or account statement presentation portal.
The system also offers secure and flexible electronic payment capabilities.
The MCM OAM capability provides:
- Documents distributed and archived to remote locations
- Native documents rendered in real-time, providing a common platform for paper or electronic submission of messages and information
- Bill presentment and e-payment capabilities
- Features and benefits page access
- Regulatory or advisory documentation views
- State Medicaid services web site integration providing common look and feel
- Future value-add information services support for state agencies
Turn to the Experts
Pitney Bowes Group 1 Software offers Medicaid Communications Management processes and services that help State agencies:
- Increase labor productivity by reducing the manual activities involved in the preparation, generation and processing of communications
- Provide providers and beneficiaries with the ability to specify their communications preferences without incremental cost or productivity loss to agency operations
- Support emerging medical record management
- Ensure data quality to improve communication precision
- Implement mass-customized communications to constituents
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