Pricing a Disease Management Program

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Pricing a Disease Management Program Powered By Docstoc
					April 25, 2011
                                                ADDENDUM #1

Under the proposal documents titled P11-04, Medical Insurance Administration Services, the following
information may help you prepare your proposal.

1. Can we get a large claims report based on a rolling 12 months March 1, 2010 through Feb 28, 2011 with the
prognosis? This is to match the claims experience provided. Also, can you indicate the plan that each of the
large claimants is on? – This can be made available if you are selected as a finalist.

2. Have there been any plan changes in 2010 or 2011? – None outside of required reform changes.

3. What are your current Wellness programs? Please describe your detailed customizations and member
incentives. – Please see information posted at The County employs an internal wellness
manager who is responsible for overseeing all wellness programs. There is a great amount of coordination
with the clinic for targeted wellness programs.

4. What services does the current administrative fee include? – Admin, HIPAA services, Utilization
Management, Pre-certification, Disease Management, Disease Management Election, Nurseline.

5. What network are you currently using? - Cofinity

6. Can members fill prescriptions at the clinic? –The clinic can dispense around 40 pre packaged generic
drugs. The clinic does not provide a full pharmacy.

7. What services does the clinic offer? – The clinic can provide about 90% of the services offered in a regular
physician’s office. All members participating in the clinic are required to fill out an HRA and complete a
biometric screening. There are several visits for every day episodic conditions. However, the majority of the
visits to the clinic are for condition/disease management and compliance follow up for underlying health
conditions. Many programs offered in traditional disease management programs are performed at the clinic.

8. Please confirm on the out patient hospital, out of network, if the coinsurance is after the out of network
deductible or after a co-pay per occurrence. – Coinsurance is after the out of network deductible. The “per
occurrence co-pay” refers to inpatient confinements.

9. Is there engagement reporting available on the Lifestyle Management Programs? How much
reimbursement has been paid to members in plan years 2010 and 2011? – Reporting is provided but is not
available at this time.

10. Who is the vendor providing the onsite clinic and are any of the clinic claims in the experience? –
Healthstat is the on site vendor. The clinic does not produce claims and no claims or costs for the clinic are
included in the experience. Services for the clinic are all inclusive based the fee for their services.

11. What is the cost to the member for using the onsite clinic and what services can they receive? – No cost to
member. Services described above and in Wellness brochure on the Larimer County web site at

12. Does the clinic bill the medical administrator for any services? – No

13. Have all healthcare reform changes been made such as removal of day limits, 100% preventative care
etc? – Yes, based on being grandfathered. The 2011 plan document has all of the 2011 changes incorporated
14. What Disease Management Programs are currently offered? And are they related to the Lifestyle
Management? – The Disease Management Program is closely monitored and highly coordinated with the
clinic. The current DM program has been customized to coordinate with the clinic. If the clinic identifies a
member needing more DM than the clinic can offer, they are referred to the TPA’s DM program. If the TPA
identifies a member needing DM, above and beyond what the clinic can offer, they coordinate and seek
approval from the clinic for managing the member. There is a very close communication system between the
TPA and the clinic. All DM is discussed and mutually decided upon between the 2 entities. This is a VERY
manual process and the clinic makes the ultimate call. Since the services for the current DM provider are
paired down due to the clinic; the cost for the DM program has been significantly reduced.

Lifestyle Management is a completely separate program. It covers programs that assist members in improving
their overall lifestyle, and includes coverage for service not typically covered, such as Weight Watchers, Stress
Management, etc. There is a special claim form and specific criteria for this program. The TPA manages this
process and reimburses members based on the criteria set forth in the plan document, Lifestyle Management
section. This is not related to the DM program.

15. Can you provide the Provider Disruption File with paid claims dollars by provider, so we can accurately
project network savings. – Not available at this time.

16. Will the selected Administrator interface with the current PBM? – Yes please provide interface feeds if

17. Please provide additional information about the onsite clinic.

          How does the provider billing work - There is no provider billing.

          What services are provided at the clinic – Described in question #7.

           How does the clinic interface with the TPA – TPA/Administrator will be required to provide monthly
claim feeds. Please provide any fees associated with file feeds. The TPA will also be expected to interface
with the clinic on DM as described in question #14.

          Are there special expectations of the TPA's customer service around the clinic. – The clinic has been
a huge success for Larimer County. It is expected that the TPA will be an advocate for the clinic and do every
thing they can to support and coordinate with the clinic.

18. What is the provider network currently being used? - Cofinity

19. On Page 2 of the RFP specifications, the Project Overview section indicates that the County wishes pricing
to be based on current plan offerings. Would the County be receptive to exploring other plan offerings/plan
designs that offer additional cost containment opportunities? – Yes, the County is always receptive to exploring
options that may provide savings. These programs will be evaluated as a component to the overall offering
and capabilities surrounding on site clinic coordination, plan design and lifestyle management administration.

20. Please provide some additional information regarding the Lifestyle Management program described on
Page 3 of the County's Summary Plan Description. Is this a component of Larimer County's internal wellness
program, or is the Lifestyle Management program a supplement to the existing health plan in place? Does the
existing carrier actually administer the courses or does the existing carrier simply handle the reimbursement of
submitted claims? – Described in question # 14.

21. On Page 10, Medical Care Management, question #10 indicates there is currently a disease management
provider that coordinates its services with the disease management services provided via the onsite clinic to
avoid duplication of efforts. Can additional information be provided regarding exactly how this takes place
(e.g., are there certain conditions that the disease management provider handles as opposed to the onsite
clinic disease management services?) – Described in question #14
22. Please outline all services provided under the current $21.50 administration fee. – Described in question

23. Please outline the description of services, fee amount and pricing model for all administration services
    provided outside of the current $21.50 administration fee (e.g. per letter or per ID card fees, or services
    billed at hourly rates such as large case management). – There is an hourly rate of $125 for large case

24. Is COBRA administration being requested? If so, please provide a detailed description of the COBRA
    services requested; e.g. will the administrator be sending the COBRA Initial Notices? – TBD

25. Does the premium/fee billing go to a single entity and/or location, or are there multiple entities and/or
    locations that are billed for and remit payment of premiums/fees? – Single location

26. Page 9, Question 13: Will claim checks be issued from a Larimer County bank account, or is Larimer
    County requesting that claim checks be issued from a bank account held by the TPA/carrier? - TBD

27. Page 10, Question 6: Please describe how MEDai serves Larimer County. – This is predictive modeling
    software provided by the clinic.

28. Page 10, Question 6: Is there an expectation that historical data for claims processed by Meritain (or other
    prior TPAs/carriers) will be loaded into the new TPA/carrier’s reporting system, or will the new TPA/carrier
    only be expected to provide data for claims processed by the new TPA/carrier? If the new TPA/carrier is
    expected to load historical data for claims processed by prior TPAs/carriers, how many years of history will
    need to be loaded? – TBD

29. Page 10, Question 8: Please describe the services provided by the on site clinic, as well as billing
    practices for the clinic. – Described in question #7.

30. Page 11, Question 1: Please define “account reconciliation reports.” – Reports provided by TPA to the
    County’s accountants that accurately match up to internal cash out reports and other paid claim data
    reports provided by the TPA.

31. Please share how the Healthstat on site clinic is staffed (nurses, PA, doctors?) - PA and MOA

32. What services does Healthstat provide? – Described in question #7 and attached PDF

33. Is there an out of pocket or plan design incentive for members to utilize the Healthstat clinic? – Cost of the
    clinic is free to members.

34. I see Healthstat gets information from the TPA, does Healthstat share encounter data to the TPA or the DM
    vendor? - Not currently could be evaluated for the right programs and circumstances.

35. Does Healthstat receive pharmacy information from the PBM – Yes
36. Does Healthstat have a pharmacy at the clinic? – Described in question #6

37. What is the weighting for the scoring system described - is it equal across all categories or more heavily
    weighted for certain categories? If so what is the weighting across categories? – TBD

38. Pg 11 question 3 - what detailed reporting do you wish the administrator to provide based on a data dump
    for wellness and non-wellness participants. – The County’s internal wellness manager tracks wellness
    participation through out the year. The County is set up with the current TPA to receive a year end data
    dump and manually ID wellness participants. To be ID as a wellness participant you must complete all
    required services for the entire year. This is why the County does not have a separate location code built
    to ID wellness and non-wellness. This information is then evaluated to determine costs and relative health
    of wellness vs non-wellness participants.

39. Is there a third party wellness vendor or an internal wellness program used to put together and track
    identified wellness programs. – There is an internal wellness manager who is responsible for overseeing all
    programs and tracking participation.

40. Please describe these wellness programs. See brochures on the Larimer County web site.

41. What are the most prevalent disease management or cost drivers for your population and what programs
    are in place to target these issues? – The on site clinic is primarily responsible for overseeing this with the

42. If we provided a quote including our integrated PBM, would this be reviewed as an option? – No, the
    current PBM – Kroger will stay in place going forward.


No further questions will be accepted or answered.

Ms. Kathryn Rowe, CPPB
Purchasing Director

Description: Pricing a Disease Management Program document sample