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Health Plans/Payer Solutions


Recognizing that every organization is unique, DST Health Solutions provides enterprise-wide and functionally rich payer platform solutions that designed to best meet the complexity and risk found in an ever-evolving health plan business environment.  Designed with the flexibility necessary to fulfill the sophisticated processing requirements of a virtually-unlimited range of health plan delivery models, DST Health Solutions provides many of the industry’s leading core claims administration and processing platforms, such as Exeter™, AMISYS Advance™, PowerMHC®, PowerMHS® and PowerSTEPP.  We’ll work with you to find the solution that supports your business and operation needs, not define them.

Exeter

Exeter is DST’s next-generation payer platform. We’ve taken the business model behind core administrative systems, workflow, and analytics and stood it on its head. Exeter frees organizations to design and implement processes and procedures that meet the strategic business demands of today’s healthcare industry – rather than forcing health plans to work around the limitations found in old, cumbersome core administrative platforms.

This cutting edge, Java-based system utilizes service-oriented architecture and can be implemented with all core administrative platforms. It is designed to integrate with external applications via web services to address ongoing change within the industry, such as the advent of Health Insurance Marketplaces, the growing necessity for data access via disparate external data systems, and consumer-driven mobile applications.

Exeter allows payers to adapt and respond more rapidly to changing market dynamics by encouraging an easier path to migration. Choosing Exeter does not have to mean a total system replacement; implementation can be achieved through what we refer to as ‘evolutionary investment.’ Simply put, you can migrate in stages – or all at once – as dictated by your organization’s strategic business needs. With Exeter you retain your existing IT investments and strategically plan for future investment, while gaining the business benefits of each adopted module.

CLICK HERE to learn more



Population health management is becoming an integral part of health plan administration as identification and resolution of care gaps, clinical coding inaccuracies, and patient safety issues become increasingly essential to health plan revenues, compliance initiatives, and member health outcomes. DSTHS’ comprehensive analytics platform, consisting of CareAnalyzer®, RiskAnalyzer™ and MDMS™, provides a complete approach to timely identification and actionable insight into your business.

The Johns Hopkins ACG® System was recently awarded the 2015 Health Services Research (HSR) Impact Award. CLICK HERE to learn more about the 2015 Health Services Award and The Johns Hopkins ACG® System.

Health Data Analysis

DST’s Health Solutions’ CareAnalyzer® allows health plans to be proactive in care management approaches, providing the tools needed to evaluate patient risk and make recommendations for better member care. Its unique analytic approach combines elements of regulatory reporting, predictive modeling, provider network evaluation, and risk adjustment—all in a single integrated system.

Manage Risk
With CareAnalyzer, you can effectively integrate member-level risk in order to better evaluate members’ needs. CareAnalyzer helps you reduce risk by allowing you to:

  • Identify member-level care gaps 
  • Avoid unnecessary utilization by identifying high-risk members for proactive, targeted intervention
  • Provide insight into provider performance and engage providers to efficiently deliver the highest quality of care

Regulatory Reporting
CareAnalyzer, an NCQA-certified HEDIS Measures CertificationSM, reports quality standards with industry-accepted HEDIS® methodology, as well as an enhanced measurement list from other industry-recognized quality organizations.

  • Measure, monitor, and manage HEDIS compliance status throughout the year
  • Satisfy the manual source code portion of the HEDIS Compliance Audit™
  • Remain current with latest specifications

Provider Network Evaluation
CareAnalyzer’s innovative analytic capabilities provide valuable insight into the performance of providers, which enables plans to better engage and educate them in support of more effective patient care.

  • Assess physicians’ prescribing patterns, including medication details, screenings, diagnostic testing, and preventive visits
  • Compare and rank providers within peer groups using client-defined benchmarking standards
  • Utilize risk profiles to identify differences in member health status across practices.

Predictive Modeling 
Seamlessly integrated into the DST CareAnalyzer product, The Johns Hopkins Adjusted Clinical Groups® (ACG®) System offers a unique approach to measuring burden of patient populations based upon disease patterns, age, and gender, relying on diagnostic and pharmaceutical code information found in insurance claims or electronic medical records. 

Risk Adjustment Analysis

In today’s healthcare environment, accurate risk adjustment is critical to ensuring optimal reimbursement levels. DST Health Solutions’ RiskAnalyzer™ uses claims and clinical data to determine where provider coding is not appropriately and consistently capturing chronic disease conditions under the CMS-HCC and HHS-HCC models. RiskAnalyzer’s innovative coding analysis allows you to identify medical records for retrospective chart review and identify those members who will benefit the most from prospective interventions, thus ensuring the highest quality of care is provided to members.

Improve Data Accuracy
Due to the aggregate impact of risk adjustment on health plan populations, failure to collect accurate data puts plans at significant risk for less revenue than the actual plan’s risk factor. With RiskAnalyzer you can:

  • Ensure accurate payments and increase revenue
  • Reduce the perpetuation of current coding inaccuracies 
  • Take full advantage of The Johns Hopkins ACG® System predictive model to identify retrospective adjustment opportunities that would be missed otherwise.

Achieve Quality Ratings Goals
RiskAnalyzer optimizes revenue adjustment strategies by providing both financial and strategic advantages that will:

  • Ensure review of chronic conditions and care gaps to deliver better quality care
  • Identify systemic issues that can be corrected with provider education
  • Positively impact Star Ratings, commercial performance incentives and state based mandates.

Predictive Modeling

Seamlessly integrated into the DST CareAnalyzer product, The Johns Hopkins Adjusted Clinical Groups® (ACG®) System offers a unique approach to measuring burden of patient populations based upon disease patterns, age and gender, relying on diagnostic and pharmaceutical code information found in insurance claims or electronic medical records.

Applications of the ACG System

Care Management
The ACG® Predictive Models are cutting edge tools that allow you to better target your case management and disease management objectives.

  • Identifies Unique Individuals for Care Management -- The ACG Predictive Models identify up to 25% more clients in need of care-management intervention before they become high utilizers 
  • Improves Care Management Processes -- Patient risk assessments can be performed quickly and on the entire population using available claims information, thereby leading to significant administrative efficiency gains. By including retail pharmacy claims in the available data, high risk patients can be identified with as little as 3 months of data.


Identifies Unique Individuals for Care Management -- The ACG Predictive Models identify up to 25% more clients in need of care-management intervention before they become high utilizers.
Improves Care Management Processes -- Patient risk assessments can be performed quickly and on the entire population using available claims information, thereby leading to significant administrative efficiency gains. By including retail pharmacy claims to the available data, high risk patients can be identified with as little as 3 months of data.

Population Profiling
Population profiling is used when comparing the morbidity patterns of one or more groups or regions. By taking into account the differences in illness burden among different patient populations, ACGs® determine variations in disease prevalence as well as resource use across groups or geographic regions.

Provider Profiling
Health care is being increasingly driven by performance, both in terms of cost efficiency and patient outcomes. The use of The ACG System offers incentives to providers to deliver appropriate, high-quality care rather than generate more episodes and additional cost. It considers the total disease experience of each patient and provides a rich array of supporting clinical variables that provide context around the provider’s treatment approach. This allows for healthcare administrators, physicians and payers to have the ability to change treatment options that may not be as effective as others when considering outcomes and cost efficiency.

Financial Analysis
The ACG® System has been widely and successfully used for capitation/rate setting, for setting insurance premiums, and for assisting in the appropriate distribution of resources within health systems of all sizes.

HEDIS

Through CareAnalyzer, we provide clients with tools to meet HEDIS reporting requirements. DSTHS participates in the NCQA HEDIS Software Certification Program™ and has successfully achieved certification status every year since 2002.

Benefits of using a certified vendor include:

  • Reduce health plan resources required to meet annual modifications to measure specifications with annual software updates
  • Verify compliance with HEDIS specifications through precise, automated testing
  • Satisfy the manual source code portion of the HEDIS Compliance Audit™

Fully Integrated Solution for Continuous Care Management Initiatives
Industry acceptance of the HEDIS methodology, the transparent nature of the measure calculations, and their stability over time make it an ideal framework for the identification of members with manageable gaps in care and a foundation for on-going quality initiatives. Using CareAnalyzer, HEDIS measures can be run not only on the standard calendar year as is required by NCQA, but on any user-defined analysis period as well. This provides health plans with a tool to continuously measure, monitor, and manage HEDIS rates throughout the year as well as to meet additional off-cycle compliance requirements.

DST CareAnalyzer uses a unique analytic approach that seamlessly interfaces the HEDIS methodology with The Johns Hopkins Adjusted Clinical Groups® (ACG®) System. Understanding of individual member risk factors and proactive management of members can reduce risk, improve quality of care, and improve HEDIS rates.

Keep Your Population Healthy
Care management gaps can be identified through consistent monitoring of members not receiving recommended services. DSTHS CareAnalyzer allows you to identify and list specific patients who met numerator and denominator criteria and/or who failed to do so – and for whom targeted interventions may be beneficial. Feedback to providers and members is supported by mail merge features which facilitate targeted mailings.

Engage Providers
CareAnalyzer utilizes HEDIS measurement in conjunction with provider attribution methods to evaluate physician’s effectiveness of, and access to, care by assessing use of medication, screening tests, diagnostic tests and preventive visits. Internal benchmarking allows comparison and ranking of providers within peer groups to assist plans in identifying provider practices where measure compliance is low, identify members in the panel not receiving recommended services and utilize the risk profile identify differences in health status across practices.

 For more information pertaining to how DSTHS can support your HEDIS reporting needs, and more, CLICK HERE.

Medical Drug Management System (MDMS)

DST's Medical Drug Management Service™ (MDMS) is a sophisticated drug management system with the proven ability to accurately apply clinical edits and reprice medical specialty pharmacy claims, all while helping to determine medical appropriateness of utilization to enforce health plan medical policy.

Far more than a simple repricer, MDMS allows plans to apply customizable clinical and pricing rules for drugs with Healthcare Common Procedure Coding System (HCPCS) Level II codes and automatically identify appropriate intervention opportunities, providing unparalleled support to payers in the form of valuable care management, operational, financial, and compliance-related data and information.

Utilize the powerful data support of MDMS to:

  • Identify provider prescribing patterns to manage your fraud, waste, and abuse (FWA) program
  • Enhance health plan medical policy and medical appropriateness through detailed clinical editing
  • Reinforce medical necessity and health plan policy by validating proper use of drugs
  • Reduce medical drug overpayments to align with industry compendia, including FDA guidelines
  • Add value to your compliance program.

CLICK HERE to learn more about the DSTHS Medical Drug Management System (MDMS).



As the U.S. population ages, the incidence of chronic conditions is increasing, which drives up the consumption of healthcare services. Payers are looking for effective ways to identify high-cost members and those at risk of becoming high-cost, so that they can manage care effectively, reduce unnecessary utilization and control costs.

The Johns Hopkins Adjusted Clinical Groups® (ACG®) System offers a unique approach to measuring morbidity that improves accuracy and fairness in evaluating provider performance, identifying patients at high risk, forecasting healthcare utilization and setting equitable payment rates.

The Johns Hopkins ACG® System Advantage

The ACG® System offers a unique approach to measuring member morbidity that improves the identification of high-risk members, enables you to evaluate provider performance fairly and accurately and to forecast healthcare utilization.

The ACG System measures the disease burden of your member population based on disease patterns, age and gender. It relies on the diagnostic and/or pharmaceutical code information found in insurance claims and electronic medical records. This provides you with a more accurate representation of the disease burden of populations, subgroups and individual patients.

The distinguishing feature of the ACG System is its "person-focused" approach, which allows it to capture the multidimensional nature of an individual's health over time.

Another important feature is the solution’s ability to describe and manage healthier populations (i.e., low users of healthcare services). Unlike other systems, ACGs were developed using commercial managed care populations as well as state Medicaid populations, which, when studied in combination, closely resemble the general population.

The ACG System has been used in commercial and research settings worldwide, longer and more extensively than any other system on the market today. It is a tried and true software product that has undergone numerous improvements and modifications in response to user needs.

Version 11.0: New Capabilities for a Changing Market

The latest release of the ACG® System, Version 11.0, brings you diverse improvements and new capabilities. Among the many enhancements:

  • Improved reporting capabilities enable you to integrate supplemental data and custom models.
  • New and revised risk-assessment markers improve the categorization of mental illness, refine frailty concepts and more.
  • New predictive models help you stratify your member population in new ways; for example, identifying persistent high users whose expenses don’t regress toward the mean.
  • And much more. 

DST offers the ACG System as an integrated component of our CareAnalyzer® solution.

CareAnalyzer provides tools with which to evaluate patient risk and make recommendations for better member care. It enables your care managers to identify gaps in care at the member level, reduce unnecessary utilization, gain insights into provider performance and better engage providers in support of improved care.

Maximize the Use of Available Data

The ACG® System provides models based on medical claims only, pharmacy claims only, or combined medical and pharmacy claims. Your analysts can choose the most appropriate model from a suite of predictive models based upon the product line, intended purpose and available data. Predictions of both total cost and pharmacy cost are available. Models that predict hospitalization are available as well.

Target Case and Disease Management Activities

The ACG® System’s Predictive Models (ACG-PMs™) are cutting-edge approaches to improved targeting of case and disease management activities. They help you transform care management, identifying many members in need of care-management interventions before they become high utilizers.

ACG-PMs will identify up to 25% more individuals for care management than other methods based on prior utilization.

The ACG System also helps you evaluate the effectiveness of disease management programs. It can also be used for quality improvement, outcomes management and case management purposes.

Find out more about The Johns Hopkins ACG System and how it can help you improve quality and outcomes while you reduce unnecessary utilization and control costs.

Call us at 800.272.4799, email us at Marketingdsths@dsthealthsolutions.com, or visit us at www.dsthealthsolutions.com



Care, Disease and Utilization Management

Focus on quality of care and improving member outcomes with CareConnect™, DST's premium care management system. CareConnect provides case managers with simultaneous access to critical medical, drug, lab, and utilization data, allowing them to connect with patients and caregivers on a personalized level throughout the care continuum. CareConnect allows health plans to provide their membership with a holistic approach to care.

Quality and Compliance
Utilize CareConnect to support your regulatory and compliance initiatives. With its standardized reporting capabilities, CareConnect helps you meet NCQA and URAC accreditation as well as CMS Medicare Advantage and Managed Medicaid regulations. Additionally, its configurable design enables plans to create and conduct member and provider participation surveys in support of quality initiatives, such as Star Ratings.

Improve Outcomes, Lower Utilization Costs
CareConnect provides plans with actionable insights that help improve productivity, giving care managers the ability to engage more members than ever before. By assisting members in avoiding hospital readmissions, choosing appropriate care settings, and managing their own health conditions, care managers can reduce utilization costs across the board. Empower your members to take a more active role in their own healthcare outcomes through an organized, personalized care experience.

CLICK HERE to learn more about CareConnect.

Appeals and Grievances

DSTHS' AWD® Appeals and Grievance solution automates the case tracking and routing process by storing and categorizing all correspondence and delivering the work to the appropriate resource based on client-defined rules. The solution is pre-configured to meet the stringent requirements for MAPD health plans, and also supports STARs, while providing the flexibility needed to tailor it to your specific processes.

Serving as an integrated and centralized repository, the Appeals and Grievance solution will receive and process all transactions regardless of the medium (email, letter, fax, and electronic), provide a means to categorize the transaction as a grievance, appeal, or complaint, and route the issue via configurable workflow per the organization's requirements. The solution incorporates triggers and escalation points throughout the process flow to ensure work is processed timely and meets regulatory requirements.

Attachments can be stored within the issues (Grievance, Appeal, or Complaint) and demographic information is captured and passed with the source documents. Comprehensive reporting is available that provides aging information, current inventory, and number and types of issues by entity (i.e. a specific member or provider).



In today’s rapidly-evolving healthcare environment, a Business Process Outsourcing (BPO) strategy can be your health plan’s key to managing transaction costs, improving service levels, and accelerating membership growth without adding infrastructure or distracting your focus from core competencies and lines of business. DST has built a reputation on delivering the most scalable and flexible health plan administration and claims processing applications in the industry.

BPO Services

DST Health Solutions gives you access to a world-class cloud-based health plan administration infrastructure, allowing you to outsource one or more discrete business functions—or your entire back office. We tailor our solutions to your specifications and provide effective mechanisms for managing results.

Front-End Processing
Let DST relieve some of your organizational and administrative burden by taking control of one or more discrete front-end functions, including content management, mail, returned mail, and distribution services, imaging, OCR, data capture/repair, and EDI file creation. In preparation for the onset of Health Insurance Marketplaces, we are also offering paper Marketplace application services.

Claims Production
DST BPO helps you process claims of all types, including HCFA/medical, UB/hospital, dental, vision, pharmacy, COB, and adjustments. Save time and money by letting us configure your system to account for coordination of benefits, and increase the efficiency of your claims process by taking advantage of our reinsurance processing, workflow management, overflow services, and subrogation processing.

Enrollment/Eligibility
DST helps you handle enrollment processing from demographics and COB to incoming files, as well as PCP changes and accept/ process non-HIPAA files. We also offer Advanced Premium Tax Credit (APTC) and Cost Share Reduction (CSR) solutions for organizations participating in Health Insurance Marketplaces.

Finance
Our finance BPO offerings include refund and void processing and negotiated vendor fees. We also provide premium reconciliation (member, APTC, and group/SHOP) and split billing specifically designed to meet the needs of Marketplace clients.e.Call Center --Our call center services provide real-time integration is ISG’s DIVA IVR system and includes scripting, open enrollment, extended hours, reporting, and open enrollment verification. For Marketplace clients, we also provide Marketplace retention support, education coverage, and billing and claims scripting.

EDI Services
Our EDI services include compliant transaction support (5010), transformation, translation, and validation, intake/output management and error resolution for all EDI transactions, trading partner management, and EDPS-CMS encounter submissions. Our Marketplace offerings include connectivity and infrastructure support for Marketplace 834 &820 via our Edge Server Solution.

Output Services
Control your customer correspondence with DST's customer communication services. We manage premium billing, member welcome packages, and direct and ad hoc mailings. We also offer check/EOB/EOP processing and membership ID card processing.

Government Business Processing and Support
Our BPO supports member financial reconciliation (CMS file services, TRR, RAPs). We provide a single-vendor solution for Medicaid and Health Insurance Marketplace reconciliation and Medicare/Medicaid management. We currently offer monthly eligibility reconciliation for Marketplace clients.

Governance Model

With our BPO governance model, you better maintain complete control over every aspect of your organization, from escalation and issue management to risk management. DSTHS is ISO 9001-certified and operates within Six Sigma principles, ensuring that our services meet industry-recognized quality standards. Our process review boards and storyboard reporting measures allow for situational analysis in order to develop a BPO setup that meets your organization’s specific business needs.

Compliance, Process and Quality Improvement

DST's proven Quality Assurance and Internal Auditing procedures are designed to support your organizations regulatory and contractual compliance obligations, including CMS regulations and Service Level Agreements. Our solutions help prepare for potential audits and avoid noncompliance sanctions and penalties.

We assist in optimizing existing processes with our multi-pass auto-adjudication and associate productivity improvement offerings and provide training and development programs to help you more efficiently utilize the skills and abilities of your staff. 

Sales and Client Support

Our experienced sales and client support teams provide your organization with individualized client solutions, pricing and implementation estimates, and sales support.

Technical Solutions

Optimize your systems configuration with our comprehensive technical solutions:
SDLCS requirements development, design review, and testing, system migrations, configuration (including Marketplace Metallic Benefit Plans), client & internal reporting, and production scheduling.

Take advantage of our more than 35 years of industry knowledge via our wide range of AWD Point Solutions, such as:

  • Claims workflow
  • Claims repair
  • Coordination of benefits
  • Claims quality audit
  • Adjustments
  • Customer service
  • Appeals and grievances intake
  • Work submission
  • Enrollment exceptions
  • Benefit plan builder.


DST Marketplace Elements® provides the technology and services you need to help secure your Marketplace success in one convenient, fully-integrated package. Specifically designed to support Qualified Health Plans participating in Marketplaces, DST Marketplace Elements can assist your organization in establishing:

  • Marketplace connectivity
  • Robust enrollment and billing functions
  •  Automated reconciliation processing
  • Care management technology
  • Risk management analytics

DST Marketplace Elements is designed to support specific areas of your Health Insurance Marketplace offering with cutting edge applications, or via our full range of Business Process Outsourcing (BPO) services. With Elements, your health plan has the established expertise of DST backing you every step of the way.

Enrollment and Reconciliation

With the implementation of Marketplaces, providers will see an increased volume of previously-uninsured customers looking for health care. DST Marketplace Elements has the enrollment functions to help handle this surge in membership, while also providing automated reconciliation processing, specifically designed to assist in administering the tax credits provided for in the ACA legislation.

Care Management

As a new population enters the Marketplace, it is imperative from a cost and quality perspective that incoming members are assessed immediately to identify those with chronic or comorbid conditions. Elements enables you to rapidly target those members who will benefit the most from disease and care management plans, ensuring that the right level of care is delivered from the onset. This approach to care management stands to significantly improve the likelihood of financial success for your organization.

The 3 Rs

Reinsurance, Risk Corridors & Risk Adjustment. Understanding how to identify and manage risk burden is an essential part of any health plan. It becomes even more critical when dealing with a member population that has little, if any, history of medical care. DST Marketplace Elements featuring DST RiskAnalyzer™, allows your organization to better manage risk, while improving outcomes and revenue.

Edge Server Solution

DST's Edge Server Solution is a comprehensive system of technology and staffing services designed to ensure Edge Server compliance and aid in Marketplace risk management. We provide the necessary tools, technology, and infrastructure to effectively manage the care—and risk—of new members while reducing the cost of Edge Server implementation and maintenance, allowing you to meet your Edge Server requirements painlessly and efficiently. 

The Edge Server is a physical server for health plans that serve individual and small group members and is used to store enrollee, medical claims and pharmacy claims information to support the Federal Marketplace Reinsurance (RI) and Risk Adjustment (RA) programs. The Affordable Care Act (ACA) mandates the Edge Server for health plans participating in Health Insurance Marketplaces and the server can be operated by the issuer or a third party.

Health and Human Services (HHS) will provide software to be downloaded and run on the Edge Server to use de-identified enrollee and claims information to gain plan level summarized data and risk score results for risk adjustment and reinsurance calculations. The Edge Server enables HHS to operate on the “edge” of operational systems.

Specifically, the DST Edge Server Solution will enable your organization to:

  • Achieve compliance with ACA Edge Server requirements
  • Implement and facilitate the use of the Edge Server
  • Save cost and personnel resources to set up and maintain the Edge Server
  • Validate and efficiently handle error correction and resubmissions 
  • Better manage member risk in ever-evolving individual and small group markets

To learn more about the DST Edge Server Solution, CLICK HERE.

Mission Critical Capabilities

DST can support your organization by providing services in the following areas that are imperative to Marketplace success.

  • Marketplace Connectivity
  • Pre-sales Support
  • Product Catalog Management
  • Enrollment Processing
  • Billing and Collections
  • Finance and AR
  • Reconciliation
  • Claims Management
  • Care Management
  • Member Support
  • Reports & Analytics
  • Renewal Processing and Retention

For more details surrounding Elements, CLICK HERE.



Enterprise Payer Platforms

Recognizing that every organization is unique, DST Health Solutions provides enterprise-wide and functionally rich payer platform solutions are designed to best meet the complexity and risk found in an ever-evolving health plan business environment.  Designed with the flexibility necessary to fulfill the sophisticated processing requirements of a virtually-unlimited range of health plan delivery models, DST Health Solutions provides many of the industry’s leading core claims administration and processing platforms, such as Exeter™, AMISYS Advance™, PowerMHC®, PowerMHS® and PowerSTEPP.  We’ll work with you to find the solution that supports your business and operation needs, not define them.

Care, Disease and Utilization Management

Focus on quality of care and improving member outcomes with CareConnect™, DST Health Solutions’ premium care management system. CareConnect provides case managers with simultaneous access to critical medical, drug, lab, and utilization data, allowing them to connect with patients and caregivers on a personalized level throughout the care continuum. CareConnect allows health plans to provide their membership with a holistic approach to care. 

Risk Analysis

In today’s healthcare environment, accurate risk adjustment is critical to ensuring optimal reimbursement levels. DST Health Solutions’ RiskAnalyzer™ uses claims and clinical data to determine where provider coding is not appropriately and consistently capturing chronic disease conditions under the CMS-HCC and HHS-HCC models. RiskAnalyzer’s innovative coding analysis allows you to identify medical records for retrospective chart review and identify those members who will benefit the most from prospective interventions, thus ensuring the highest quality of care is provided to members.

Improve Data Accuracy -- Due to the aggregate impact of risk adjustment on health plan populations, failure to collect accurate data puts plans at significant risk for less revenue than the actual plan’s risk factor. With RiskAnalyzer you can:

  • Ensure accurate payments and increase revenue
  • Reduce the perpetuation of current coding inaccuracies
  • Take full advantage of The Johns Hopkins ACG® System predictive model to identify retrospective adjustment opportunities that would be missed otherwise

Achieve Quality Ratings Goals -- RiskAnalyzer optimizes revenue adjustment strategies by providing both financial and strategic advantages that will:

  • Ensure review of chronic conditions and care gaps to deliver better quality care
  • Identify systemic issues that can be corrected with provider education
  • Positively impact Star Ratings, commercial performance incentives and state based mandates.

Population Health Analysis

DST's CareAnalyzer® allows health plans to be proactive in care management approaches, providing the tools needed to evaluate patient risk and make recommendations for better member care.  Its unique analytic approach combines elements of regulatory reporting, predictive modeling, provider network evaluation, and risk adjustment—all in a single integrated system.

HCC Revenue Cycle Management

Combining solutions and strengths already inherent in DST offerings, we’ve taken our world-class population health analytics products (RiskAnalyzer™ & CareAnalyzer®) and integrated them with our business process management technology expertise to provide the services associated with the retrospective risk adjustment process. Powerful analytics, in-office chart retrieval, sophisticated coding technology, and a cadre of well trained, highly efficient, certified coders, make DST HCC Retrospective Risk Adjustment Services a world-class partner in delivering the right revenue for the risks undertaken by the Medicare Advantage plan.

Revenue Analytics and Suspect Identification
Given that high risk patients consume more care resources, plans must take appropriate, proactive steps to ensure they are receiving the proper reimbursement for care provided. Since the CMS bid rate does not always accurately reflect the actual burden of care required for the members of a specific plan, it is imperative that the plan match revenue for risk accepted. Plans face a number of challenges with this payment method: diagnoses must be gathered and submitted each year, assuring the specificity and accuracy of provider coding, mechanized systems that carry diagnosis codes forward or deleted diagnosis codes. In order to combat these inaccuracies in data, plans need a robust analytics engine.

Our solution was created by a cadre of medical economists, clinical review experts and data process analysts to assure its ability to identify members, disease burden, and appropriate risk adjustment, as well as provide financial insight in an exceptionally efficient manner. DST's’ risk adjustment analytics application generates a better suspect list because it does not rely solely upon claims data. Through the integration and utilization of lab data, pharmacy claims, medication compliance, and other ancillary clinical data, we are better able to identify those medical records most appropriate for review.

Inherent in the solution is the predictive modeling power of The Johns Hopkins ACG® System, which allows for additional identification of suspect members for review. We also assign and estimate a probability of successful risk adjustment for each member identified on the suspect list. This probability adjusted capture is used to determine, in conjunction with the client, the prioritization of both member and provider selection at each step of the risk adjustment process – member selection, provider selection, chart retrieval, etc. In addition to suspect identification, we are able to quantify in a probability adjusted format, the revenue associated with the HCC adjustment, along with the likelihood of achieving that revenue adjustment.

Simply put, DST’s solution makes it possible to access massive and ever-increasing amounts of data in a variety of ways in order to ensure the efficient, accurate identification of members, the rapid retrieval of charts, and the in-depth chart analysis and coding, and maintain a realistic projection of expected returns from the risk adjustment process.

Medical Record Retrieval & Review
DST’s HCC coding platform uses AWD Business Process Management workflow, queues, and rules to seamlessly automate and evaluate the medical record abstraction process. Providing tighter control over data management issues, rules and probability based algorithms are in place to best identify potential abstraction errors for correction. DST utilizes its highly trained staff of HCC coders to extract all diagnoses from the medical record and in-home assessments to ensure revenue accuracy.

DST has partnered with a nationally recognized medical record retrieval firm and has the ability to capture charts anywhere in the U.S. While most firms rely on faxed and mailed in-charts, DST's partner is on site in the providers' offices for over 90% of the charts. This results in better chart collection success and more secure transmission of sensitive patient information.

DST’s experienced coders are highly skilled, full-time, certified coding professionals trained in various coding paradigms to support the retrospective risk adjustment revenue management programs, including CMS HCC management for Medicare Advantage and HHS HCC management for the Health Insurance Marketplace. DST uses its training and quality assurance framework to deliver a combination of classroom and system based training programs to ensure strong initial training combined with ongoing coaching and performance evaluation. Finally, DST maintains its coding professionals year round with other assignments rather than treat them as seasonal workers. This provides much better motivation and job satisfaction which translates into better performance and success for our clients.

Our coding professionals analyze and code every diagnosis in the medical record, not just those identified as potential HCC gaps. Performed as a blinded abstraction exercise, coders can focus on efficient abstraction while DSTHS HCC coding platform matches the abstracted data to the correct HCC and revenue adjustment. DST also maintains a team of dedicated specialists that ensure the validity of the HCC matches as well as ensuring the integrity of the process. Finally, the results are reviewed by an internal QA team to validate results and confirm adherence to audit policies.

Data Submission Services
Medical records reviews and claims data are translated into the required format for submission to CMS via RAPS/ EDPS, thereby closing the loop on the retrospective risk adjustment process. For those plans participating in Health Insurance Marketplaces, DST provides an Edge Server Solution for HHS reinsurance and risk adjustment processing.

Encounter Data Processing Solutions

Producing compliant, CMS-ready encounter transactions, this comprehensive solution enforces HIPAA edits and CMS rules to prevent non-compliant transactions from being submitted to the CMS EDPS. Our solution is designed and maintained based on HIPAA standards and CMS requirements.

The powerful reporting engine provides insight and control through secure portal technology. Clients are able to access and share detailed information including volume statistics, success rate, and drilldown error reports to automate error correction. All reports are exportable into industry standard formats. Online reporting and automation decrease time-consuming error correction research. Features include:

  • Form-based transaction views providing detailed, easy-to-read error reporting with direct links to detailed descriptions of problems. Users do not need EDI expertise to locate and understand errors.
  • On screen error correction enables users to correct and resubmit encounter transactions with real-time validation.

DST’s EDPS Solution works with source data from any claim processing system and is 100% HIPAA compliant. The solution has been developed utilizing the CMS Companion Guides and rule sets and is regularly updated to meet current guidelines. It does not require end-users to maintain any additional rules-based engines, mapping documents, or requirements. Using this solution, you can reduce plan resource requirements needed to meet and maintain CMS encounter submission compliance. Our core team, made up of CMS and EDPS subject matter experts, is dedicated to consulting with health plans to ensure their success with encounter data submissions to CMS.

To learn more about the DSTHS EDPS Solution, CLICK HERE.



Population Health Analysis

DST Health Solutions’ CareAnalyzer® allows health plans to be proactive in care management approaches, providing the tools needed to evaluate patient risk and make recommendations for better member care.  Its unique analytic approach combines elements of regulatory reporting, predictive modeling, provider network evaluation, and risk adjustment—all in a single integrated system.

STAR Rating Improvement
The Centers for Medicare and Medicaid Services (CMS) utilizes a quality rating system for Medicare Advantage plans. The system measures a plan’s quality of care, access to care, responsiveness and member satisfaction. Originally, the STAR system's primary focus was the collection and reporting of data. The shift in measures has now moved to an outcomes based process.

Plans are measured on multiple domains, utilizing a 1-5 scale. CMS assigns the plan’s ratings in October for the following plan year, based on the plan sponsor’s most recent quality performance data. For example, on average for 2011, Medicare Advantage plans scored 3.47 STARS, with PDP plans scoring 3.11 STARS.

Considering the benefits of being a high performance plan, such as increased bonuses and extended enrollment periods, utilizing DSTHS to maximize STAR ratings, improve population health, and ensure the accuracy of Risk Adjustment Factors just makes sense.

The following products and services are encompassed in the DST STAR Ratings approach:

  • Robust Enterprise Payer Platform
  • Customer Service 
  • Appeals and Grievances 
  • Population Health Analytics
  • HEDIS Reporting
  • Predictive Modeling
  • Pay for Performance Administration (P4P)

LEARN MORE about the DST STAR Rating Improvement Solution, click here. <Link to STARs brochure>

 

 

Risk Analysis

In today’s healthcare environment, accurate risk adjustment is critical to ensuring optimal reimbursement levels. DST Health Solutions’ RiskAnalyzer™ uses claims and clinical data to determine where provider coding is not appropriately and consistently capturing chronic disease conditions under the CMS-HCC and HHS-HCC models. RiskAnalyzer’s innovative coding analysis allows you to identify medical records for retrospective chart review and identify those members who will benefit the most from prospective interventions, thus ensuring the highest quality of care is provided to members.

Improve Data Accuracy -- Due to the aggregate impact of risk adjustment on health plan populations, failure to collect accurate data puts plans at significant risk for less revenue than the actual plan’s risk factor. With RiskAnalyzer you can:

  • Ensure accurate payments and increase revenue
  • Reduce the perpetuation of current coding inaccuracies 
  • Take full advantage of The Johns Hopkins ACG® System predictive model to identify retrospective adjustment opportunities that would be missed otherwise.

Achieve Quality Ratings Goals -- RiskAnalyzer optimizes revenue adjustment strategies by providing both financial and strategic advantages that will:

  • Ensure review of chronic conditions and care gaps to deliver better quality care
  • Identify systemic issues that can be corrected with provider education
  • Positively impact Star Ratings, commercial performance incentives and state based mandates.

Enterprise Payer Platforms

Recognizing that every organization is unique, DST provides enterprise-wide and functionally rich payer platform solutions that are designed to best meet the complexity and risk found in an ever-evolving health plan business environment.  Designed with the flexibility necessary to fulfill the sophisticated processing requirements of a virtually-unlimited range of health plan delivery models, DST Health Solutions provides many of the industry’s leading core claims administration and processing platforms, such as Exeter™, AMISYS Advance™, PowerMHC®, PowerMHS® and PowerSTEPP.  We’ll work with you to find the solution that supports your business and operation needs, not define them.

Encounter Data Processing Solutions

Producing compliant, CMS-ready encounter transactions, this comprehensive solution enforces HIPAA edits and CMS rules to prevent non-compliant transactions from being submitted to the CMS EDPS. Our solution is designed and maintained based on HIPAA standards and CMS requirements.

The powerful reporting engine provides insight and control through secure portal technology. Clients are able to access and share detailed information including volume statistic, success rate, and drilldown error reports to automate error correction. All reports are exportable into industry standard formats. Online reporting and automation decrease time-consuming error correction research. Features include:

  • Form-based transaction views providing detailed, easy-to-read error reporting with direct links to detailed descriptions of problems. Users do not need EDI expertise to locate and understand errors.
  • On screen error correction enables users to correct and resubmit encounter transactions with real-time validation.

DST’s EDPS Solution works with source data from any claim processing system and is 100% HIPAA compliant. The solution has been developed utilizing the CMS Companion Guides and rule sets and is regularly updated to meet current guidelines. It does not require end-users to maintain any additional rules-based engines, mapping documents, or requirements. Using this solution, you can reduce plan resource requirements needed to meet and maintain CMS encounter submission compliance. Our core team, made up of CMS and EDPS subject matter experts, is dedicated to consulting with health plans to ensure their success with encounter data submissions to CMS.

LEARN MORE about the DST EDPS Solution, click here.

Care, Disease and Utilization Management

Focus on quality of care and improving member outcomes with CareConnect™, DST's premium care management system. CareConnect provides case managers with simultaneous access to critical medical, drug, lab, and utilization data, allowing them to connect with patients and caregivers on a personalized level throughout the care continuum. CareConnect allows health plans to provide their membership with a holistic approach to care.

Quality and Compliance
Utilize CareConnect to support your regulatory and compliance initiatives. With its standardized reporting capabilities, CareConnect helps you meet NCQA and URAC accreditation as well as CMS Medicare Advantage and Managed Medicaid regulations. Additionally, its configurable design enables plans to create and conduct member and provider participation surveys in support of quality initiatives, such as STAR Ratings.

Improve Outcomes, Lower Utilization Costs
CareConnect provides plans with actionable insights that help improve productivity, giving care managers the ability to engage more members than ever before. By assisting members in avoiding hospital readmissions, choosing appropriate care settings, and managing their own health conditions, care managers can reduce utilization costs across the board. Empower your members to take a more active role in their own healthcare outcomes through an organized, personalized care experience.

LEARN MORE about CareConnect.



Population Health Analysis

DST’s CareAnalyzer® allows health plans to be proactive in care management approaches, providing the tools needed to evaluate patient risk and make recommendations for better member care. Its unique analytic approach combines elements of regulatory reporting, predictive modeling, provider network evaluation, and risk adjustment—all in a single integrated system.

The Centers for Medicare and Medicaid Services (CMS) utilizes a quality rating system for Medicare Advantage plans. The system measures a plan’s quality of care, access to care, responsiveness and member satisfaction. Originally, the STAR system's primary focus was the collection and reporting of data. The shift in measures has now moved to an outcomes based process.

Plans are measured on multiple domains, utilizing a 1-5 scale. CMS assigns the plan’s ratings in October for the following plan year, based on the plan sponsor’s most recent quality performance data. For example, on average for 2011, Medicare Advantage plans scored 3.47 STARS, with PDP plans scoring 3.11 STARS.

Considering the benefits of being a high performance plan, such as increased bonuses and extended enrollment periods, utilizing DSTHS to maximize STAR ratings, improve population health, and ensure the accuracy of Risk Adjustment Factors just makes sense.

The following products and services are encompassed in the DST STAR Ratings approach:

  • Robust Enterprise Payer Platform
  • Customer Service 
  • Appeals and Grievances 
  • Population Health Analytics
  • HEDIS Reporting
  • Predictive Modeling
  • Pay for Performance Administration (P4P)

LEARN MORE about the DST STAR Rating Improvement Solution, click here. <Link to STARs brochure>

Risk Analysis

In today’s healthcare environment, accurate risk adjustment is critical to ensuring optimal reimbursement levels. DST’s RiskAnalyzer™ uses claims and clinical data to determine where provider coding is not appropriately and consistently capturing chronic disease conditions under the CMS-HCC and HHS-HCC models. RiskAnalyzer’s innovative coding analysis allows you to identify medical records for retrospective chart review and identify those members who will benefit the most from prospective interventions, thus ensuring the highest quality of care is provided to members.

Improve Data Accuracy
Due to the aggregate impact of risk adjustment on health plan populations, failure to collect accurate data puts plans at significant risk for less revenue than the actual plan’s risk factor. With RiskAnalyzer you can:

  • Ensure accurate payments and increase revenue
  • Reduce the perpetuation of current coding inaccuracies 
  • Take full advantage of The Johns Hopkins ACG® System predictive model to identify retrospective adjustment opportunities that would be missed otherwise.

Achieve Quality Ratings Goals -- RiskAnalyzer optimizes revenue adjustment strategies by providing both financial and strategic advantages that will:

  • Ensure review of chronic conditions and care gaps to deliver better quality care
  • Identify systemic issues that can be corrected with provider education
  • Positively impact STAR Ratings, commercial performance incentives and state based mandates.

Enterprise Payer Platforms

Recognizing that every organization is unique, DST Health Solutions provides enterprise-wide and functionally rich payer platform solutions that are designed to best meet the complexity and risk found in an ever-evolving health plan business environment.  Designed with the flexibility necessary to fulfill the sophisticated processing requirements of a virtually-unlimited range of health plan delivery models, DST Health Solutions provides many of the industry’s leading core claims administration and processing platforms, such as Exeter™, AMISYS Advance™, PowerMHC®, PowerMHS® and PowerSTEPP.  We’ll work with you to find the solution that supports your business and operation needs, not define them.

Encounter Data Processing Solutions

Producing compliant, CMS-ready encounter transactions, this comprehensive solution enforces HIPAA edits and CMS rules to prevent non-compliant transactions from being submitted to the CMS EDPS. Our solution is designed and maintained based on HIPAA standards and CMS requirements.

The powerful reporting engine provides insight and control through secure portal technology. Clients are able to access and share detailed information including volume statistic, success rate, and drilldown error reports to automate error correction. All reports are exportable into industry standard formats. Online reporting and automation decrease time-consuming error correction research. Features include:

  • Form-based transaction views providing detailed, easy-to-read error reporting with direct links to detailed descriptions of problems. Users do not need EDI expertise to locate and understand errors.
  • On screen error correction enables users to correct and resubmit encounter transactions with real-time validation.

DST’s EDPS Solution works with source data from any claim processing system and is 100% HIPAA compliant. The solution has been developed utilizing the CMS Companion Guides and rule sets and is regularly updated to meet current guidelines. It does not require end-users to maintain any additional rules-based engines, mapping documents, or requirements. Using this solution, you can reduce plan resource requirements needed to meet and maintain CMS encounter submission compliance. Our core team, made up of CMS and EDPS subject matter experts, is dedicated to consulting with health plans to ensure their success with encounter data submissions to CMS.

LEARN MORE about the DST EDPS Solution, click here. <Link to EDPS brochure.>

Care, Disease and Utilization Management

Focus on quality of care and improving member outcomes with CareConnect™, DST Health Solutions’ premium care management system. CareConnect provides case managers with simultaneous access to critical medical, drug, lab, and utilization data, allowing them to connect with patients and caregivers on a personalized level throughout the care continuum. CareConnect allows health plans to provide their membership with a holistic approach to care.





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