Conduct audits quarterly to identify provider compliance and educational opportunity. Establish baseline overall compliance and specific focus areas.

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2 continuous improvement. Program Area: Quality Improvement, Outreach, and Education Activity: Conduct CHEC audit and provide physician feedback* Aim: Promote evidencebased and cost-effective care, clinical guidelines, and covered benefits and services, to our members and providers CQI management, wellness programs and automation of the utilization processes. Outcome reporting with robust data analysis will be a critical component to the redesign. Staff roles will be redefined to fit the population demographics, benefit design and contractual regulations. Low compliance was noted in the previous audit (2010) in regards to head circumference measurements and adolescent blood pressure. Non- Compliance was noted in the 0-24 month group for social emotional screening, blood lead, metabolic, and hematocrit testing, and dental referrals. Missed blood pressures and urinalysis tests were also noted in Conduct audits quarterly to identify provider compliance and educational opportunity. Establish baseline overall compliance and specific focus areas. adopted risk contracts and have demonstrated success in their outcome reporting. 4. Evaluate data analysis tools for provider engagement related to reviewing utilization, cost and quality outcomes. 5. Write a case management program description identifying key players, roles and responsibilities along with the key components of focus. This will be addressed with a collaborative model of other University of Utah providers and staff along with the services provided by external providers and agencies. 1. Pull data according to the CHEC Audit P & P 2. Use the audit tool quarterly to review provider compliance. 3. Run a CHEC report by provider to capture CPT billed CHEC services. 4. The CHEC report will be used to pull a random selection of providers to complete the CHEC dataset that is not able to be captured on a claim i.e., BMI, head part in the Crimson Analytics analysis and data input. 5. Care management program description outlined, staff hired, teams developed with provider engagement. Active committees in place for U Baby and ED Diversion. Clinical Advisory Committee identified with plan to meet monthly. MET Reports were run for FY 2012 and 2013 using claims data to capture CHEC measures for total pediatric population. A chart review was conducted to monitor documentation teams have progressed well and the new staff have been able to adapt quickly. Chart review is time consuming but the only true way to monitor compliance 2 of 16 Each team will have their core physician leaders to assist with best practice, patient engagement and treatment plan design. Continue per contract

3 *Carryover from FY2012 Program Area: Culturally and Linguistically Appropriate health care Services Activity: Implement online EduCat training* Aim: Maintain an effective CLAS program that supports member needs and promotes customer satisfaction. pre-teen and adolescent groups. Results were shared with the provider groups. In the 2012 redesign of the audit tool and reporting to identify key areas that can be captured through the claim submission. Random provider audits on clinical measures that are not able to be captured by a CPT code. Focus will be to incorporate the behavioral health social networking issues pertaining to the CHEC indicators. UUHP maintains an effective CLAS program for both the Healthy U and Healthy Advantage products. One component of this program is annual cultural competency training to staff. Currently, this is a manual process conducted in staff meetings and in new hire training. Moving this training to the University Health Care Implement on-line training through EduCat by June 30, 2013 circumference, height and weight. The EMR will be used for all University providers and fax requests will be made for non-university providers. 5. Enrollment will provide the enrollee membership by age to establish a baseline for targeting 90% adherence to CHEC guidelines. 6. Work to establish the baseline measure to target benchmarks into FY Review results with providers, providing specific names of patients where educational opportunities are identified. 1. Determine components of training (See Healthy Advantage Training) 2. Develop power point 3. Develop quiz questions 4. Provide information to training department for implementation 5. Test training / ensure part of annual requirements for staff 6. Integrate into new hire training NOT MET The PowerPoint and quiz were developed and given to the department this year via . CLAS training will be pushed to an online automated system in 2014, see constraints The University switched from EduCat to LMS, in May No changes to the system were allowed from May July 2013, preventing us from moving the CLAS training to an automated system. 3 of 16 Move CLAS to LMS FY 2014.

4 *Carryover from FY2012 EduCat system will automate and standardize the training. 7. Promote to staff for explanation. Program Area: Customer Service and Satisfaction Activity: Plan Link Implementation* Aim: Provide high-quality customer service that promotes customer satisfaction *Carryover from FY2012 Program Area: Customer Service and Satisfaction Activity: CAHPS Survey Employee Plan Aim: Provide high-quality Healthy U will implement Plan Link beginning in Plan Link is a provider portal allowing providers to review claims, eligibility, referrals, EOBs, and payments on line. Healthy U assesses member satisfaction annually using CAHPS Consumer Assessment of Health Care Providers and Systems. CAHPS data is used to identify administrative, Ten participating providers by 6/30/13 Complete CAHPS for both Healthy U and UCHP in Implementation of hardware 2. Customization of Epic software 3. Marketing, branding 4. Staff Education 5. Testing / Go live 4 of 16 Weekly meetings established 07/2012 with Systems & Marketing 1. Contact the state and Data Stat to identify the process of including both Healthy U and in the 2013 CAHPS survey. 2. Supply enrollment files for both plans. PARTIALLY MET Test and production environments are completed and undergoing alpha testing. Beta testing is scheduled to begin by September 1, 2013, with roll out to ten providers by 12/31/2013. We are simultaneously developing a prototype to create a seamless look and feel for providers in Epic. MET CAHPS Surveys were completed for both Healthy U and UUHP Hospital and Clinics Employee The project was more resource intense than originally anticipated, requiring push back on our original target implementation date. This is the baseline year for UUHP Hospital and Clinics results, so we will benchmark to like commercial plans Continue Continue CAHPS for both Healthy U and employee plans.

5 customer service that promotes customer satisfaction Program Area: Fraud and Abuse Prevention and control Activity: Program Refinements* Aim: Implement interventions to curb fraud, waste, and abuse. *Carryover from FY2012 service, and clinical quality improvement initiatives, monitor health plan performance against local and national benchmarks, and to assess overall member satisfaction as an indicator of whether Healthy U is meeting customer expectations. This year will incorporate the employee plan, University Health Care Plus (), into the CAHPS survey. We formalized a fraud and abuse compliance program in The program will be evaluated and enhanced during FY Communicate with staff and key stakeholders. 4. Evaluate and compare results with local and national benchmarks. 1. Review and implement applicable Patient Protection and Affordable Care Act (PPACA) regulations. 2. Run a new set of data through HCI to identify code edit violations, potential patterns of fraud/abuse, and provider outliers 3. Review program description, leadership based on new department infrastructure, and tracking tools. plans through the state s vendor DataStat. Healthy U Plan Rating (% 8, 9, or 10) 72.89% State Average % UUHP Hospital & Clinics Plan Rating of Health Plan (% 8, 9, or 10) 76% State Average 55.92% MET Trained providers in areas of Fraud, Waste, & Abuse to correct practices. Audited providers with potential abuse, collecting approximately 75K in refunds. and national norms. Due to system changes and new product development, new claims editing tool for Fraud, Waste, & Abuse still in process. 5 of 16 1.Implement new claims module adding additional Fraud, Waste, & Abuse edits. 2.Increase frequency of data sets through HCI to identify code edit violations, potential patterns of fraud/abuse, and provider outliers. 3.Continue to review program description and leadership

6 Program Area: Information Systems Activity: Finalize HIPAA transactions* Aim: Continually improve information systems to support overall health plan improvement *Carryover from FY2012 UUHP is fully compliant with the Privacy Act. New and existing employees receive required training annually, all members receive a notice of privacy practices, and UUHP maintains P & Ps to protect private information. UUHP is finalizing EDI and code set transaction requirements in the following areas: /271 Health Care Eligibility/Benefit Inquiry and Information Response /277 Health Care Claim Status Request and Response Health Care Services Review Request for Review and Response: UUHP does not require priorauthorization and verified with the CMS that this transaction did not apply. We will implement it after all other transactions so that providers can The 270/271 and 276/277 will be implemented by 1/1/13 1. Complete internal system testing 2. Develop documentation for internal staff 3. Educate internal staff on changes to existing process via staff meeting 4. Complete pre notification testing with University Physicians and University Hospital 5. Train responsible staff on new procedures for testing, implementing and maintaining trading partners 6. Go live with University Physicians and University Hospital 7. Notify external trading partners of ability to begin testing 8. Update department web site with information on available transactions 9. Notify UHIN of change from internal testing to external testing 10. Begin pre notification testing with external trading partners 11. Go live with external PARTIALLY MET The 270/271 went live on 1/1/13. The 276 went live on 4/22/13. We have received a few 270 transactions and no 276 transactions. Resources for 278 were reallocated since we have a low prior auth rate and UHIN has had no 278 activity from providers. Most of these data reside in our system, however, we have not been able to derive helpful data from the chie. 6 of 16 based on new department infrastructure and tracking tools. No carry over

7 Program Area: Operations Activity: Identify the reasons for claims adjustments and decrease the total number of adjustments. Aim: To improve accuracy of claims processing. requests courtesy preauthorizations electronically if desired. With the implementation of the Epic claims processing system we no longer have a method of tracking claims adjustments. The Operations Director and the Systems Director have a potential concern around the number of claims that have been adjusted to make corrections to the implementation and build of Epic. The two directors will work this year to redevelop a reporting mechanism that can display the trend of adjustments. Corrective action plans will be put in place to improve the accuracy of Epic and decrease the adjustments trend. Decrease the claims adjustment trend trading partners 12. Ongoing testing and go live with external trading partners as they are ready Programmer training completed 08/2012 Test file received from internal trading partner 08/2012 Comparison of system functionality compared to CORE requirements completed 07/2012 Develop reports based on adjustments Analyze / Trend data based on date of service Remove corrected claims from the data set Identify reasons for adjustments Establish benchmarks Create a corrective action plan for prevention of future adjustments Include systems auditing from the compliance area MET We developed reports based on adjustments, have the ability to analyze the data based on date of service, and are able to identify reasons for adjustments. We established a benchmark based on the number of adjustments for FY 2012 and implemented auditing. We decreased the total number of adjustments: Healthy U (30% ) FY12 68,758 New systems are in place requiring new processes to be developed. 7 of 16 Further develop reporting functionality and improve our ability to report on adjustments Continue to develop and perform system audits Trend and analyze based on dates of service Focus on high volume adjustment projects to

8 FY13 48,710 Overall (15% ) FY 12 96,020 FY 13 82,428 identify areas of improvement. Evaluate the impact of the JIRA system on preventing future adjustments Program Area: Information Systems Activity: ICD-10 implementation* Aim: Continually improve information systems to support overall health plan improvement *Carryover from 2012 In 2009 the HHS published two final rules (45 CFR Parts 160 and 162) mandating the adoption of updated HIPAA standards. The first rule requires updating 4010 HIPAA transactions with the new 5010 transactions by January, The second rule requires replacing ICD-9-CM codes with ICD-10 codes by October 2013 CMS has proposed a potential delay to October Implementation complete by October Internal needs assessment 2. Participation in University committees to identify implementation issues-in progress (Epic Testing Team, ICD10 Metrics, ICD10 Financial Impact) 3. Determine training needs 4. Internal build 5. Epic test environment for ICD10 created 08/2012 PARTIALLY MET The Epic build of rules, case management, referrals, benefits, vendor contracts, and fee schedules will be completed by 10/1/13. The two outstanding areas are reporting (Clarity and Reporting Workbench) and the ices (code editing) upgrade to 5.0. The ices upgrade should be completed by 11/1/13. We plan to begin internal testing with hospital and Epic reporting will require assistance from our Data Warehouse team and we don t yet know when that will be completed. Continue 8 of 16

9 physician electronic claims files 1Q2014 followed by external partners in 2Q Program Area: Information Systems Activity: Convert policies and procedures into a management system (SharePoint) allowing form systematic reviews, approvals, categorizing, and searching. * Aim: Continually improve information systems to support overall health plan improvement. *Carryover from FY2012 University of Utah Health Care is implementing an enterprise-wide solution to P & P management, which allows users to systematically review, approve, categorize, and search policy documents. UUHP will convert P & Ps to this system, which will improve our ability to manage our P & Ps for operations and audit purposes. Convert P & Ps by 1/1/13 1. Meet with U IT/Communication s team to outline process to convert policies to SharePoint. 2. Department meetings to discuss conversion steps, consistent formats, and timelines. 3. Quality review of policies after conversion to ensure accuracy and consistency. 4. Staff training regarding new system. MET Training to learn the process and convert P&Ps went smoothly. UUHP created a test work group in early January to work through P&Ps while ensuring accuracy and checking for inconsistencies. Updates were sent to department throughout process and formal announcement and training were given in early February. P&Ps were officially live in mid- February. There were no constraints; in fact, we completed our P&P conversion in such a timely manner that we lead the Health Care teams in the conversion process. Policies and procedures will continue to be maintained in SharePoint. Routine activity will not be carried over to the FY14 plan. 9 of 16

10 Program Area: Information Systems Activity: Develop an audit process to ensure that providers, vendors, contracts and the provider database were setup / populated accurately. Aim: Continually improve information systems to support overall health plan improvement. *Carryover from FY2012 The Provider Database is a resource for staff to look up provider information used for claims processing, customer service, and provider directories, among other uses. Increasing the accuracy of the Provider Database records will result in more accurate provider directories, better customer service to members and providers, a decreased number of misdirected payments, and increased efficiency during the credentialing process, all of which are dependent upon an accurate Provider Database. Ensure the accuracy of the Provider Database records 1. Research off the shelf software versus the internally developed program. 2. Develop Policy and Procedure to outline Provider Database Audit process 3. Audit a percentage of new providers records for accuracy 4. Audit a percentage of new providers contract files for accuracy 5. Audit a percentage of credentialing files for accuracy 6. Update data as changes are required PARTIALLY MET Outside vendor solutions were reviewed by the team. We have moved forward with remediating the home grown system to make it easier to support. Large vendor group updates needed for Epic and the PB are now being completed in both systems by IT staff to assist with accuracy and consistency. About 10% of the files that are credentialed and re-credentialed annually were audited for accuracy. Due to the project to determine if the home grown system should be replaced, the auditing processes were not actively worked on this year. Continue 10 of 16

11 Program Area: Quality of Care Activity: ACO readiness assessment, development, and implementation of new payment methodologies* Aim: - Clear, patient focused aims, provider accountability through transparent performance measures that reflect those aims - Providers are able to monitor and report performance in improving health and lowering costs, and are supported by financial and professional incentives (payment & contracting methodologies) that are aligned with achieving better health and lowering costs for their patients -Align payment methodologies with measurable, meaningful progress in improving health care while lowering costs^ *Carryover from FY2012 CQI In 2010, the Utah Legislature passed Senate Bill 0180, which required all Medicaid health plans to move to an ACO model. The State of Utah has determined January 1, 2013 as the implementation date. The concept of ACO s is to shift from episodic care to population/disease management which relies heavily on collaboration, communication and transparency between PCP, specialists, other health care service providers, patients, health plan. There are various methods of payment methodologies that are being developed and implemented across the country based on size, integration and current measures that exist in various organizations. Fee-for-Service (FFS) cash flow is not going away anytime soon. Initially there may be a greater reliance on FFS as quality incentives and shared Implement initial basic methodology with supporting meaningful, measurable quality initiatives by 1/2013. Layer additional incentives as further initiatives are developed and implemented with quarterly reviews on effectiveness 1. Review Huron consultants best practices/recommendati ons- compare to what is currently measured and how 2. Review literature, attend conferences and association meetings to ascertain best practices and process around the country 3. Work in Collaboration with Care and Utilization Management in review of on-site visits of academic organizations, data analysis tools and care management initiatives 4. Engage physician, clinic, hospital and plan leadership in alignment of measuring improvement in quality standards and receiving payments when such improvements occur 5. Establish criteria for physician participation in quality measures and incentives to set expectations 6. Make certain we have the claims, support system and reporting capabilities to measures PARTIALLY MET A comprehensive review of literature, coupled with onsite visits at like organizations was completed and shared with the governing committees throughout the year. Implementation of the new Value Based Payment Methodology was effective with the University Primary Care Physicians and their associated clinics July 1, See Value Based Payment Method Executive Summary (Attachment A) for additional information about the four payment components: 1. Standard fee Implementation delayed in order to ensure adequate provider understanding of and training on the model. Move value based payment methodology to other providers in the network. 11 of 16

12 Program Area: Quality of Care Activity: Develop discrete data elements in EpicCare to be used for HEDIS reporting. Aim: - Implement interventions that improve member care and health status. CQI savings are developed, implemented, monitored and refined. As additional measures and quality incentives are realized, reliance on FFS should transition in part to other payment methodologies such as FFS with payment Pay-for Performance, Partial/Full Capitation, Bundled Payments, etc. HEDIS audit completed through internal/external chart review, by the Care Management team. Identified opportunities to implement or refine reporting data found in EpicCare. Identify elements that will support care delivery and improve health status of members. provider compliance, pay claims correctly, identify incentives earned, proper patient attribution to measure progress, and appropriate measures to show increase quality at lower cost 7. Revise contract and credentialing process as needed to reflect quality and payment changes 8. Look to improve methodologies and measures as we progress in implementation of initiatives 1. Crimson analytics program was purchased, to help with data analysis and to identify high risk members. 2. Other analytical programs will be reviewed for Care Management enhancements, including for service payments. 2. Enhanced fee for service payments. 3. Population management /thin cap payment 4. Shared savings program. Care management and Quality improvement initiatives are also part of the collaboration with the University PCP s and can be found in the same document. MET 1. Actively engaged with Crimson validation of Healthy U and UUHP data. 2. Conducted teleconferen ces and webinars Time lag from validation to complete install. 12 of 16 Roll out Crimson Analytics to Health Plan care managers and the community clinic care managers to assist with providerattributed

13 Program Area: Quality of Care Activity: Review and continue process of mail and phone reminders to members. Aim: - Implement interventions that improve member care and health status. CQI In FY 2012, mail and phone reminders went to members, who were missing diabetic eye exam or mammogram documentation. Reminders were also part of the U Baby Care program and other case management efforts. The Care Management team will review the communications this year and determine effectiveness. Increase effectiveness of reminder type communications with members. HEDIS data identification. 3. HEDIS standard reminders to physicians, that will support care delivery. 4. Streamline the data collection process for HEDIS. 1. Mail and phone reminders will go out to members enrolled in Care Management programs. 2. Letter and phone communications will be reviewed for effectiveness. 3. New communication styles will be addressed; social media, My Chart, etc. with multiple other software vendors and decided to work with EPIC. 3. HEDIS letters forwarded to providers. 4. Worked with consultant on the reportable HEDIS measures. MET This area has had a lot of attention and revamping. Phone contact is in place with the CM teams, however, Televox reminder calls were put on hold. We are engaged with MyChart, the chie, social networking. CM websites were established for providers. Not having accurate addresses and phone numbers. Messages left and reaching a live person was a very small %. Working with the vendors of chie and MyChart for care manager access and transferability. groups and patient profiles. Continue to expand other ways of reaching out to members and providers through technology. 13 of 16

14 Program Area: Quality of Care Activity: Standardize criteria tools Aim: Adopt standardized criteria across the care continuum Measure quality of care using standardized and validated measures, and achieve quality rates that demonstrate community leadership. CQI Standardization of criteria across the Health Plan system could enable our providers in knowing the expectations of determining medical necessity for requested services and ongoing patient needs. This could minimize the utilization functions and allow more emphasis on care management of our patient population. It helps to reduce the unknown and the number of denials due to lack of needed documentation to support the request. A standardized criteria tool also provides a unified foundation when referencing denial and/or appeals. Introduce and adopt a nationally recognized criteria for UM decisions (inpt, outpt, and other areas of focus, e.g., DME, etc.) 1. Review with Leadership team, Quality Committee inclusive of the Medical Directors in determining importance of a standardized criteria tool. 2. Assess the # of parties that would utilize the criteria and the electronic interface capabilities. 3. Determine institutional costs to effectiveness of outcomes 4. Identify reports that can be disseminated to key players demonstrating the value of a standardized criteria base. MET Have revamped UM processes to assure that the processes assist in identifying key components for care management Worked with systems and ops teams to use electronic interfaces and establish rules to adhere to benefit and criteria language. Reviewed cost and utilization reports to establish preimplementation and continued to review monthly with implementation. Establishing consensus on what needs top priority. Multiple factors can sway importance: high cost, staff time, complexity of implementation. This will continue to be a focus for our next year. The streamlining processes in UM and other departments of Health plan is critical for us to help increase efficiencies. Monthly reports are shared with our committee members reporting utilization, quality, and cost. The key teams 14 of 16

15 Program Area: Quality of Care Activity: Behavioral Health Assessments Aim: - Implement interventions that improve member care and health status. CQI In FY 2013, it will be important to address behavioral health issues and the impact on medical care. In the past (2008 and 2009), Healthy U partnered with VMH to implement 3 interventions for care coordination. This intervention did not result in the impact that was expected and therefore the intervention was discontinued for FY Moving forward with the ACO and Medical Home development it will be necessary to work with the Primary care providers in identifying behavioral health issues that have an impact on medical conditions. It has been shown that addressing behavioral health concerns, i.e., depression, anxiety, Introduce a Quality of Life measure for use in the Primary Care practices. RAND short form 12 (SF12). 1. We will track how many patients are screened for major depression by a report showing diagnosis code 296.2, These patients would be identified for case management tracking. 3. Report quality outcomes using the Analytics tool by provider by the case managed group. 4. Share reporting with provider teams related to value (quality + cost) and outcome reporting. are U Baby, inpatient, restricted, pharmacy high cost, and ED Diversion PARTIALLY MET Behavioral health assessment tool was developed in collaboration with the UUHP care management team. The healthy U members were identified that have mental health diagnosis with their medical chronic conditions. Crimson analytics has been implemented by the management team to review quality outcomes, cost and utilization. Outcome reporting has been developed on the financial, Incorporating the behavioral health and medical health is relying on claims data of the provider billing practice to incorporate all diagnosis codes (mental health and medical codes) GATE Utah is being tested with the commercial population to determine utilization and process needs before implementing it for the Healthy U members. 15 of 16 Continue

16 sleep, has a positive impact on treating medical conditions jointly. More patient compliance and self-empowerment occurs along with less missed workdays. The Health plan case managers will work with the Primary care providers to identify a tool to help assess the patient s perceived quality of life (QOL measure). utilization and operational standards. These reports are shared with the Advisory Board, staff meeting and individual team meetings, i.e. U Baby Program, ED Valued Committee, Inpatient team and other hospital, physician-led committees. Introduces the GATE Utah psychiatric consult webbased services for the UUHP Hospital and Clinic employees at 9 community clinic sites and University Pediatric clinic. Plan is to offer these services to the Healthy U members. 16 of 16