The client, a leading health insurer for a Medicaid Managed Care health plan in the Northeast serving over 330,000 members.
The organization decided to migrate all existing acute inpatient hospital contracts to All Patient Refined Diagnostic Related Groups reimbursement. The implementation had to address all aspects of introducing a new reimbursement methodology to the plan’s hospitals, including new contract templates, communication and education, medical and payment policies and procedures, revised operating policies and procedures, financial analysis and modeling, system configuration processes and implementing a new technical solution to group and price claims that would be integrated into the existing claims system.
This project involved updating the integration between the APR DRG grouper/pricer solution and the legacy claims system. The solution introduced a web services based approach to submit claims for grouping/pricing and then load the results into the claims system. It also included a significant amount of redesign and implementation regarding additional claims automation within the legacy system.
Ninestone was brought in to provide comprehensive program management and direction, day-to-day project management, medical and payment policy and operational implementation support, and training and documentation support. In addition, we provided detailed technical solution design and implementation expertise. A program PMO was established, along with operational, clinical, technical and communications project teams to address different aspects of the implementation.
Ninestone incorporated risk identification and mitigation plans while providing a holistic approach to project management, aligning technical design with organizational strategies. Program management included the establishment of a formal Project Management Office to effectively manage and incorporate cross functional expertise. Improved stakeholder communication provided necessary transparency.
Ninestone led the program to a successful and timely pilot implementation, addressing issues related to operational, clinical and technical claims payment as well as working directly with the pilot hospital system to address questions/concerns. The program has since been fully implemented and is achieving operational efficiency and financial savings targets.