BEFORE PRISM
Acme Health uses various tools and spreadsheets.
Members are assigned to Acme by the government who has set a per member capitation that they will pay to tAcme based on patient profiles (85% for medical losses, 10% for admin, 5% for Acme profit). If medical losses increase, already thin margins vanish quickly.
Susan Jones, 55 year old diabetic, is an Acme member. She's a frequent ER visitor. 80% of the time she's treated in the ER, and released, 20% of the time she is transitioned to inpatient.
Susan visits a wellness center, but the wellness center staff is not able to access her all or most current medical history (claims, episodes, prescriptions). Therefore, Acme is unable to impart best quality care.
Another very low risk member, Andy's eligibility is about to expire in 90 days and there is no recertification alert in the system. The outreach process is out of sync.
Acme's executives of Finance/Care Management/Quality Care/Compliance Management/Operations/IT have limited staff to analyze the member profiles or costs. Therefore, they cannot categorize member population to target specific preventive and interventional care for the highest improvement in quality and cost reduction.
Additionally, on an ad-hoc basis, the government requests Acme management to submit various reports. Because the existing data systems often have inconsistent data, the reports are inaccurate, time-consuming, and expensive to compile.
Steve Stevenson, MD is an Acme network provider. His claim submission process seems to be overbilling Acme. Acme is running simple spreadsheets (or, third party software) that makes detection time consuming and cumbersome.
Fraud investigation is complex and document intensive. Investigator output is disorganized across the fraud team, with no easy system for notes and tracking. Therefore, fraud investigation often has a low return on investment.
Compliance for every period is a huge red flag for Acme. Additionally, Supplemental data is all over the place.
Acme works with many partners who share data with Acme, but Acme data is fragmented and duplicated.
Executives and managers have no dashboards.
Acme is very inefficient - things need to change. Patients are not receiving quality care, investors are not getting expected RoI.
AFTER PRISM
Acme has implemented PRISM.
The implementation and training process take 6-8 weeks. There are no extra hardware costs, as PRISM is on the cloud.
With PRISM, Susan Jones is immediately identified as a high-risk member, and PRISM creates alerts for such a member for customized care management. This increases visibility
into high-risk members - with automated processes.
When Susan visits the wellness center, the staff counsel has access to all her data. The counsel is efficient, guides her on how to avoid ER visits, and to seek outpatient care instead. Her quality
of life improves reducing overall costs for such a member. A quality team member can generate a task and assign to appropriate associate to ensure Susan
gets attention. At the same time, Andy's status generates a recert alert so Acme does not lose him as a cost-efficient member.
When the government requests Acme's management to provide any kind of data, the reports are created from a single dataset, and are consistent. Report generation is simple and quick.
Acme uses PRISM to manage the ingesting of data from the many agencies and vendors who share data with Acme:
- wellness facilities sharing member visit details
- CRISP type data taking real-time ER/IP encounters into account to create role-based alerts
- government agencies sharing legacy/supplemental patient data
- government agencies sharing data for quality audits
The outreach team has a comprehensive program including recerts, outreach, transportation help, doctor appointments, alternative addresses/phone/PCPs, and a full log of activities carried of
any member. This log saves the day when audit comes calling - as each and every Acme action is logged to paint a complete picture of patient-user interaction.
Steve Stevenson, MD submits a fraudulent claim. PRISM's machine learning algorithm suspects fraud, and automatically sends an email to Acme's Fraud Management
team to alert them. Using PRISM's comprehensive documentation and tracking system, the fraud team can manage all the
emails, notes, invoices, and tasks in a central location, accessible to the whole team. This availability and transparency immensely streamlines investigations reducing overall costs.
Executives and managers have range of dashboards.
All the business data is organized in PRISM, and is accessible to all the relevant Acme team members per their roles. With PRISM, Acme MLR, and ALR are controlled, Acme is always in compliance.
Acme members receive high quality health care. The Acme investor group are proud of the quality care they provide their community, and are assured of a good return on their investment.
PRISM has been a big help!
Subsequently, in the following sit to eight weeks implementation and training period, both the old system and the new PRISM are used side-by-side. Only when the staff is fully comfortable with the validity of PRISM do they stop using the old system and migrate over to PRISM.
PRISM was designed by Karma Strategies, which has built and managed many data systems for a variety of organizations across the United States.