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HomeMy WebLinkAboutRESPONSE - RFP - P682 BENEFITS (16)• p A '+ p P cn M � P.roposalto- Provi•de 1Vledic"I Bene zts Submitted�tc DIN offerl CdIloll a . 1 x y- u. r s i 1 You, your doctor and Paci tCar City of Ft Collins 1999 PROSPECTIVE RATE Total POS POS -RX POS PAID CLAIMS Paid Claims (07/01/97 - 06/30/98) $91,789 $42,848 $134,637 Less Claims over $135,000 $0 $0 Adjusted Paid Claims $91,789 $42,848 $134,637 / Employee Months (05/01 /97 to 03/31 /98) 920 920 920 = Paid Claims PEPM $99.77 $46.57 $146.34 x Trend (6.0% Med & 14.0% RX Annual for 18 Months) 1.0913 1.2172 1.1314 Expected Future Claims $108.88 $56.69 $165.57 CAPITATION Paid Capitation (07/01 /97 - 06/30/98) $67,668 $67,668 /Employee Months (07/01 /97 - 06/30/98) 928 928 = Capitation PEPM $72.92 $72.92 x Trend (3.0% Annual for 18 Months) 1.0453 1.0453 = Expected Future Capitation $76.22 $76.22 Expected Claims Plus Capitation $185.11 $56.69 $241.80 x Adjustment for Prior Year Plan Change 1.000 1.000 1.000 = Adjusted Expected Claims and Capitation $185.11 $56.69 $241.80 Manual Claims PEPM $287.27 $60.10 $347.37 Credibility (POS 30%) $256.62 $59.08 $315.70 Current Expected Claims PEPM $270.26 $49.57 $319.83 Projected Increase -5.05% 19.18% -1.29% 7/27/98 01 /01 /96 - 12/31 /96 ABC COMPANY ABC00 Analysis Of Injury & Poisoning Page 14 Injury & Poisoning claims accounted for 14.5% of the payments in this period, and 18.9% of the claimants. Average Paid Relationship Claimants Days Payment per Claimant Employees 100 23 103,079 1,031 Spouses 19 0 3,959 208 Children 120 2 64,822 540 Total 239 25 $171,860 S719 Age Band Claimants Days Payment Ave Paid 1-19 96 1 47,860 499 20-34 49 8 42,503 867 35-49 55 3 40,377 734 50-64 39 13 41,121 1,054 Leading Diagnosis Claimants Days Payment Ave Paid 844 SPRAIN KNEE 22 1 45,503 2,068 996 GRAFT REPLACEMENT 5 9 13,079 2,616 997 SURG COMPL-BODY SYST NEC 2 9 12,867 6,434 845 SPRAIN OF ANKLE FOOT 16 0 11,647 728 821 FX FEMUR 2 0 9,474 4,737 824 FX ANKLE 3 0 8,855 2,952 864 [NJ LIVER 2 4 7,803 3,901 884 WND UPR LIMB MOLT UNSPEC 1 0 7,020 7,020 836 DISL KNEE 8 0 6,628 829 814 FX CARPAL 2 0 3,870 1,935 Admission Type Admits ALOS Ave Paid Ave/Day Medical 9 2.8 4,108 1,479 Total 9 2.8 4,108 1,479 01 /01 /96 - 12/31 /96 ABC COMPANY ABC00 Page 15 Analysis Of Pregnancy & Childbirth Pregnancy & Childbirth claims accounted for 10.3% of the payments in this period, and 10.6°% of the claimants. Average Paid Relationship Claimants Days Payment per Claimant Employees 79 58 89,999 1,139 Spouses 15 7 14,069 938 Children 40 20 17,519 438 Total 134 85 $121,587 S907 Age Band Claimants Days Payment Ave Paid Less than 1 7 18 14,380 2,054 1-19 33 2 3,138 95 20-34 65 51 79,937 1,230 35-49 29 14 24,132 832 Leading Diagnosis Claimants Days Payment Ave Paid 661 OB LABOR ABNORMALITIES 4 13 17,514 4,379 648 OB MOTHER COMPL 2 12 16,473 8,237 V30 SINGLE LIVEBORN 8 19 14,846 1,856 664 PERINEAL TRAUM W DELIVER 9 9 12,179 1,353 656 FETAL PROB AFFECTING MGT 4 4 6,872 1,718 658 AMNIOTIC CAVITY/MEMBRANE 4 5 6,207 1,552 V22 NORMAL PREGNANCY 38 0 5,460 144 647 OB COMP INFEC 1 3 5,169 5,169 652 FETAL MALPOSITION 2 3 4,629 2,314 650 OB NORMAL DEL 3 4 3,924 1,308 Admission Type Admits ALOS Ave Paid Ave/Day Normal Del 27 1.3 1,427 1,133 C-Sections 6 5.3 7,416 1,390 Medical 2 2.0 2,140 1,070 Newborn 4 3.8 2,649 706 Total 39 2.2 2,510 1,152 nl/01/96 - 12/31 /96 ABC COMPANY ABC00 Page 1 G Analysis Of Digestive System Digestive System claims accounted for 10.2% of the payments in this period, and 6.2% of the claimants. Average Paid Relationship Claimants Days Payment per Claimant Employees 63 37 97,141 1,542 Spouses 6 5 12,473 2,079 Children 10 6 11,047 1,105 Total 79 48 $120,661 $1,527 Age Band Claimants Days Payment Ave Paid Less than 1 2 0 383 192 1-19 4 6 9,124 2,281 20-34 10 1 9,327 933 35-49 27 2 27,878 1,033 50-64 36 39 73,949 2,054 Leading Diagnosis Claimants Days Payment Ave Paid 574 CHOLELITHIASIS 10 11 30,120 3,012 560 INTEST OSTRU W/O HERNIA 4 19 25,719 6,430 550 HERNIA INGUINAL 7 0 14,419 2,060 530 ESOPHAGUS DISEASES OF 13 7 14,037 1,080 540 APPENDICIT ACUTE 5 10 12,455 2,491 562 DIVERTICULA OF INTESTINE 4 1 5,910 1,477 558 COLITIS/GASTROENTERITIS 10 0 3,989 399 523 GINGIVAL/PERIODONTAL DIS 1 0 2,361 2,361 565 ANAL FISSURE FISTULA 3 0 2,203 734 564 DIGES DISORDERS NEC FUNC 5 0 1,932 386 Admission Type Admits ALOS Ave Paid Ave/Day Medicat 14 3.4 4,609 1,344 Total 14 3.4 4,609 1,344 01 /01 /96 - 12/31 /96 ABC COMPANY ABC00 Page 17 Analysis Of Skeleton & Muscle System Skeleton & Muscle System claims accounted for 8.8% of the payments in this period, and 10.7% of the claimants. Average Paid Relationship Claimants Days Payment per Claimant Employees 85 5 56,802 668 Spouses 20 10 26,555 1,328 Children 31 1 21,354 689 Total 136 16 $104,712 S770 Age Band Claimants Days Payment Ave Paid, 1-19 25 1 21,364 855 20-34 21 0 14,952 712 35-49 54 3 37,190 689 50-64 34 12 30,509 897 65 and over 2 0 696 348 Leading Diagnosis Claimants Days Payment Ave Paid 717 KNEE INT DERANGEMENT 18 0 24,028 1,335 726 PERIPH ENTHESOPATHIES 11 10 17,799 1,618 722 INTERVERTEBRAL DISC DIS 10 6 12,362 1,236 719 JOINT DISORDER NEC NOS 24 0 11,796 492 724 BACK DISORDER NEC NOS 22 0 8,416 383 727 TENDON/BURSA DIS 7 0 6,714 959 718 DERANGE JNT OTHER 4 0 6,061 1,515 733 BONE/CART DISORDERS OTHE 3 0 5,855 1,952 729 SOFT TISS DISORDERS OTHE 16 0 4,470 279 723 CERV RGN DISORDERS OTHER 6 0 3,322 554 Admission Type Admits ALOS Ave Paid Ave/Day Medical 6 2.7 3,758 1,409 Total 6 2.7 3,758 1,409 Sample PPO Sherlock Report 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 ABC COMPANY PPO SHERLOCK GROUP NUMBER ABC01 Contents Overview . . . . . . . . . . . . . . . . . . . . . 1 Analysis Of Dental Claims . . . . . . . . . . . . . 2 Analysis Of Medical Claims . . . . . . . . . . . . 3 Total Medical Claimants . . . . . . . . . . . . . . 3 Claimant Age Analysis . . . . . . . . . . . . . 4 Paid Claims By Cause . . . . . . . . . . . . . . . 5 Provider Information . . . . . . . . . . . . . . . 6 Provider And Vendor Discount Savings . . . . . . . 7 Payments By Benefit Category . . . . . . . . . 8 Laboratory Expense . . . . . . . . . . . . . . . . 9 Inpatient Utilization . . . . . . . . . . . 10 Catastrophic Illness . . . . . . . . . . . . 11 Analysis Of Skeleton & Muscle System . . . . . . 12 Analysis Of Tumors . . . . . . . . . . . . . . . 13 Analysis Of Symptoms & Signs . . . . . . . . . . 14 Analysis Of Mental & Substance Abuse . . . . . . 15 Analysis Of Pregnancy & Childbirth . . . . . . . 17 Analysis Of Injury & Poisoning . . . . . . . . . 18 Analysis Of Genitourinary System . . . . . . . . 19 1 1 /01 /96 - 12/31 /96 ABC COMPANY Overview Page 1 ■ The total RIMS claims paid were $1,506,658. No conventionally funded third party drug claims are included in this total. ■ Medical paid claims totaled $812,110 with 185 inpatient hospital days. Employees Spouses Children 5658,030 $57,961 596,119 ■ Dental paid claims totaled $694,549. Employees Spouses Children 5482,704 $67,826 $144,019 ■ There were a total of 38 admissions, of which 1 contained coordination of benefit payments. ■ Total medical expense associated with inpatient admissions was $214,637 (26%), while outpatient care expense was $597,472 (74%). The period covered was January 1, 1996 through December 31, 1996 and only claims paid on RIMS in that period were considered. This report was processed on September 24, 1997. `1 /01 /96 - 12/31 /96 ABC COMPANY Analysis Of Dental Claims The distribution of dental claims by major dental categories was: Employees Spouses Children Total DIAGNOSTIC 71,827 9,804 28,100 109,732 ENDODONTICS 29,454 7,589 2,610 39,652 GEN SERVICES 11,192 1,830 5,180 18,202 NOT ADA CODE 16,988 2,321 6,866 26,174 ORAL SURGERY 10,041 3,047 21,580 34,668 OTHODONTICS 1,776 0 22,499 24,275 PERIODONTICS 42,164 4,904 1,653 48,721 PREVENTIVE 75,676 8,639 33,610 117,925 PROSTHO FIXED 15,908 0 1,815 17,722 PROSTHO REMOVE 3,445 2,009 0 5,453 RESTORATIVE 204,233 27,685 20,107 252,025 Total S482,704 $67,828 $144,020 S694,549 The leading dental care providers during this time frame were: Paid Provider Name City State Amount RONALD F LAMBERT DOS LOUISVILLE CO $17,160 MICHAEL SHORE DDS LOUISVILLE CO $12,880 GREGG T ROGERS DDS BOULDER CO $12,150 THOMAS M SIMPSON DDS BOULDER CO $12,039 F ROBERT MURPHY DDS BOULDER CO $11,747 JA14ES ABRAMOWITZ DOS LONG14ONT CO $10,921 KENNETH POULSEN DOS BOULDER CO $10,837 WM A BRACHVOGEL DDS BOULDER CO S10,693 W V KITTLE14AN DOS BOULDER CO $10,0& WAYNE D ZARLENGO DDS LOUISVILLE CO $9,604 STEVEN L EURICH DDS LAFAYETTE CO $9,477 MARK J BIRNBACH DMD BOULDER CO $9,196 TERRY L DAVIS DDS BOULDER CO S9,152 EDWARD P THEISS DOS BOULDER CO S9,048 SHELLEY KAPPEL DDS BOULDER CO $8,928 GERALD B SAVORY DDS BOULDER CO 58,350 ROBERT J BAXT BOULDER CO $8,235 GILES B HORROCKS DDS BOULDER CO S7,693 MARTIN C FRYE DDS BOULDER CO $7,479 DANA J JOHNSON DDS BOULDER CO $7,446 Page 2 11 /01 /96 - 12/31 /96 ABC COMPANY Page 3 Analysis Of Medical Claims The distribution of medical payments by Relationship (Employees active or retired, Spouses, and Children) compared to PacifiCare experience was: Employees PacifiCare Norms 60% Percentage of Paid 81% Total Medical Claimants Spouses Children 24% 16% 7% 12% The medical claimants were identified by unique SSN's, first names, and relationship codes for individuals with medical claims. This approach does not count the number of claims, just the number of individuals filing claims. In the absence of complete insured data, it is the best method we have to derive utilization averages. Relationship Claimants Paid R&B Days Admits Employees 584 658,030 176 34 Spouses 67 57,961 0 0 Children 205 96,119 9 4 Total Claimant 856 5812,110 185 38 Average Medical Payments per Claimant / Days and Admits per 1000 Claimants: Days per Admits per Relationship Average Paid 1000 Claimants 1000 Claimants Employees 1,127 301 58 Spouses 865 0 0 Children 469 44 20 Claimant Average S949 216 44 y 1 /01 /96 - 12/31 /96 ABC COMPANY Claimant Age Analysis Page 4 This analysis looks at the ages of the claimants. The ages were calculated at the end of the period, so only a single age is assumed for the entire period. This insures consistency between the various claimant counts. If the age was calculated when the claim was paid, many claimants would be counted at more than one age (if claims were paid both before and after their birthdate). Average Claimant Age by Relationship: Relationship Average Claimant Age Employees 47.2 years old Spouses 50.4 years old Children 12.9 years old The average age of medical claimants was 39.2 years old. The PacifiCare norm is about 35.3 years Experience by Age Bands: Paid Ave Paid per Age Band Claimants Amount Claimant R&B Days Less than 1 3 1,419 473 0 1-4 17 9,278 546 3 5-9 32 8,000 250 0 10-14 67 21,798 325 0 15-19 60 50,216 a37 6 20-24 29 4,097 141 0 25-29 24 16,537 689 3 30-34 34 35,825 1,054 10 35-39 62 100,189 1,616 37 40-44 97 63,142 651 4 45-49 156 142,200 912 10 50-54 134 94,366 704 1 55-59 81 208,598 2,575 108 60-64 44 44,740 1,017 0 65-69 9 6,869 763 0 70-74 4 1,798 449 0 75-79 1 176 176 0 Over 79 2 2,862 1,431 3 Total 856 S812,110 $949 185 City of Ft Collins 1999 PROSPECTIVE RATE Total HMO HMO -RX HMO PAID CLAIMS Paid Claims (07/01/97 - 06/30/98) $1,050,766 $234,298 $1,285,064 Less Claims over $50,000 $0 $0 Adjusted Paid Claims $1,050,766 $234,298 $1,285,064 / Employee Months (05/01 /97 to 03/31 /98) 6,432 6,432 6,432 = Paid Claims PEPM $163.37 $36.43 $199.79 x Trend (4.0% Mad & 14.0% RX Annual for 18 Months) 1.0606 1.2172 1.0891 Expected Future Claims $173.26 $44.34 $217.60 CAPITATION Paid Capitation (07/01 /97 - 06/30/98) $403,402 $403,402 /Employee Months (07/01 /97 - 06/30/98) 6,695 6,695 Capitation PEPM $60.25 $60.25 x Trend (3.0% Annual for 18 Months) 1.0453 1.0453 = Expected Future Capitation $62.99 $62.99 Expected Claims Plus Capitation $236.25 $44.34 $280.59 x Adjustment for Prior Year Plan Change 1.000 1.000 1.000 = Adjusted Expected Claims and Capitation $236.25 $44.34 $280.59 Manual Claims PEPM $259.77 $61.33 $321.10 Credibility (HMO 100%) $236.25 $44.34 $280.59 Current Expected Claims PEPM $230.85 $33.28 $264.13 Projected Increase 2.34% 33.23% 6.23% 7/27/98 1/0 1 /96 - 12/31 /96 ABC COMPANY Page 5 Paid Claims By Cause Specific information about each medical claim is accumulated in the form of the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9) coding convention. These codes are from 3 to 5 digits in length, and reflect the doctor's perception of the problem. The codes are grouped into diagnostic categories which identify bodily systems (or causes). Experience for this period was as follows: Paid % of R&B % of Cause Amount Paid Days Days Claimants Skeleton & Muscle System 139,552 17.2 11 5.9 330 Tumors 94,211 11.6 12 6.5 115 Symptoms & Signs 92,861 11.4 41 22.2 713 Mental & Substance Abuse 77,523 9.5 30 16.2 195 Pregnancy & Childbirth 77,183 9.5 40 21.6 109 Injury & Poisoning 68,513 8.4 0 0.0 245 Genitourinary System 67,629 8.3 10 5.4 352 Respiratory System 44,860 5.5 2 1.1 520 Digestive System 34,344 4.2 9 4.9 115 Nervous Sys/Sense Organs 32,213 4.0 4 2.2 186 Infections & Parasitic 31,827 3.9 19 10.3 98 Circulatory System 17,504 2.2 5 2.7 92 Glands & Metabolism 17,109 2.1 2 1.1 109 Skin & Skin Related 10,123 1.2 0 0.0 171 Blood Related 3,456 0.4 0 0.0 6 All Others/Supplementary 1,731 0.2 0 0.0 14 Birth Defects 1,040 0.1 0 0.0 18 Perinatal Conditions 430 0.1 0 0.0 2 Total $812,110 185 3,390 The leading individual (medical) ICD-9 diagnoses were: Paid % of R&B X of ICD-9 Diagnosis Amount Paid Days Days Claimants 722 INTERVERTEBRAL DISC D 29,172 3.6 3 1.6 14 296 PSYCHOSES AFFECTIVE 26,041 3.2 16 8.6 27 174 CA BRST F 24,901 3.1 0 0.0 8 200 LYMPHOSARC/RETICULOSA 24,501 3.0 0 0.0 1 053 HERPES 20STER 23,583 2.9 16 8.6 3 650 OB NORMAL DEL 19,992 2.5 0 0.0 7 309 ADJUST REACTION 17,470 2.2 0 0.0 55 724 BACK DISORDER NEC N 16,786 2.1 4 2.2 43 202 CALYMPHOID/HISTOCYTIC 13,715 1.7 10 5.4 1 300 NEUROTIC DISORDERS 13,338 1.6 2 1.1 43 `1 /01 /96 - 12/31 /96 ABC COMPANY Provider Information Claim payments went to the following recipients: Paid % of Amount Paid Paid to Non -Hospital Providers S480,866 59.2 Paid Directly to Hospitals S291,488 35.9 Paid to Insured S39,645 4.9 Joint Assignments $109 0.0 Page 6 The leading hospital providers for this time frame were: ( * denotes a PacifiCare Preferred or Network Provider - not just those associated with the client's PPO) R&B Paid Provider Name City State Days Amount *BOULDER COMMUNITY HO BOULDER CO 84 $163,528 *PORTERCARE HOSP-AVIS DENVER CO 41 S55,194 *SWEDISH MEDICAL CENT DENVER CO 1 $24,901 *LONGMONT UNITED HOSP LONGMONT CO 9 $15,079 *CHILDRENS HOSPITAL DENVER CO 0 $11,150 *LUTHERAN HOSPITAL WHEAT RIDGE CO 0 $2,404 *POUDRE VALLEY HOSPIT FT COLLINS CO 37 $2,148 *UNIVERSITY HOSPITAL DENVER CO 0 $2,128 *PORTER MEMORIAL HOSP DENVER CO 0 S1,985 *ST ANTHONY HOSP-NORT DENVER CO 0 $1,846 *MCKEE MEDICAL CENTER LOVELAND CO 0 $1,686 *AURORA REG MEDICAL C AURORA CO 0 $1,400 *ESTES PARK MEDICAL C ESTES PARK CO 0 $1,330 *ROBERT BLISS MD BOULDER CO 0 $1,263 WINNESHIEK CNTY MEMO DECORAH IA 0 S785 MARY HITCHCOCK MEMOR LEBANON NH 0 S753 HOSPITAL BASED CRNA ENGLEWOOD CO 0 $675 VANDERBILT UNIV MED NASHVILLE TN 0 $641 DENVER HEALTH AND NO DENVER CO 0 $496 *NORTH COLO MEDICAL C GREELEY CO 0 S481 *NTL JEWISH CTR FOR 1 DENVER CO 0 S446 MISSOULA COMMUNITY H MISSOULA MT 0 $333 *NORTH SUBURBAN MED C THORTON CO 0 $229 ST LUKES REG MED CEN BOISE ID 0 -. $142 BOZEMAN DEACONESS HO BOZE14AN MT 0 $124 '' 1 /01 /96 - 12/31 /96 ABC COMPANY The leading non -hospital providers were: R&B Paid Provider Name City State Days Amount *PATRICK MORAN MD BOULDER CO 0 $118,317 *KYLE M FINK MD DENVER CO 0 $17,640 *CORNING CLINICAL LAB DENVER CO 0 $17,030 *COMMUNITY HOMECARE BOULDER CO 1 $16,264 COLORADO PSYCHIATRIC DENVER CO 12 $14,977 *UNIV PHYS - PEDIATRI DENVER CO 0 $9,756 *WILLIAM FERRIS MD DENVER Co 0 $9,151 *BOULDER RADIOLOGISTS BROOMFIELD CO 0 58,406 *KIDNEY STONE CENTER DENVER CO 0 $7,452 *MARY MACSALKA MD BOULDER Co 0 $7,105 Provider And Vendor Discount Savings Page 7 The savings from Provider and Vendor Discounts amounted to $365,988 and the details are as follow: ------------ Network ------------- --- Non -Network --- Category Charged Savings Charged Hospital Facility 305,767.61 109,906.80 34,801.61 Physician Service 901,250.10 243,991.99 251,104.37 Other 49,028.84 12,088.85 36,270.25 TOTALS $1,256,046.55 5365,987.64 5322,176.23 Overall percentage savings for in -network client charges were 29.1 %, and 79.6% of charges were from network providers. nl/01/96 - 12/31 /96 ABC COMPANY Payments By Benefit Category The medical payments by benefit category during this period were: Paid % of PacifiCare Amount Paid Norm Medical Care 231,978 28.6 21.1 Hospital Expense 174,489 21.5 34.6 %-Ray 8 Lab 128,546 15.8 12.9 Miscellaneous 112,943 13.9 10.4 Surgery 111,953 13.8 12.0 Anesthesia 22,668 2.8 2.8 Emergency Care 18,659 2.3 0.4 Drugs 10,875 1.3 4.2 Page 8 nl/01/96 - 12/31 /96 ABC COMPANY Page 9 Laboratory Expense Laboratory expense totaled $73,718.36 in this period. These laboratory expenses are divided into two categories: standard pathology and laboratory procedures (8xxxx CPT-4 codes) and hospital medical services (9xxxx CPT-4 codes). The pathology and laboratory expenses totaled $53,429 while the hospital medical expenses were $20,289. PacifiCare has national contracts in place in certain markets that provide lab services at substantial discounts to charges found in many local markets. Your PacifiCare representative can review your situation to see if your expenses might be a candidate for this program. The leading standard pathology/laboratory procedures were: Amount Average Procedure Number Eligible Eligible 88305 SURG PATH, SINGLE -NOT CO 89 10,002 112.38 89399 MISC PATHOLOGY LAB PROC 115 8,895 77.35 88267 CHROMOSOME COUNT: AMNIOT 3 1,664 554.53 85025 HEMOGRAM/PLATLT;AUTO CBC 130 1,597 12.28 85024 HEMOGRAM/PLATLT;MAN DIF 93 1,580 16.99 84443 RIA ASSAY OF TS HORMONE 79 1,522 19.26 80019 19 OR MORE BLOOD/URINE T 113 1,305 11.55 80061 LIPID PROFILE 33 866 26.23 82670 RIA ASSAY OF ESTRADIOL 17 858 50.45 88156 TBS SMEAR (BETHESDA SYST 42 826 19.66 80092 THYROID PANEL W H STIM 24 749 31.20 83718 BLOOD LIPOPROTEIN ASSAY 60 6" 10.74 The leading providers of pathology/laboratory services were: Amount Average Provider City Number Eligible Eligible *CORNING CLINICAL LAB DENVER 1,104 16,972 15.37 *BOULDER COMMUNITY HO BOULDER 64 4,307 67.29 *PATHOLOGY SERVICES P DENVER 78 4,103 52.60 *GEORGE P HENRY MD DENVER 10 2,088 208.76 BOULDER VALLEY PATHO BOULDER 15 1,619 107.93 ROCKY MOUNTAIN PATHO DENVER 14 1,086 77.60 *STEPHEN HONG MD BOULDER 15 1,022 68.13 *UNIVERSITY HOSPITAL DENVER 8 1,006 125.72 THE CENTER FOR REPRO ENGLEWOOD 12 915 76.25 11 /01 /96 - 12/31 /96 ABC COMPANY Inpatient Utilization Page 10 This analysis deals with weekend admissions and the average length of stay (ALOS). For the weekend admission analysis, all accident, pregnancy -related, and newborn admissions have been omitted from the admission counts. The total number of admissions in this period was 38, of which 27 were not accident, pregnancy, or newborn admissions. Weekend Admissions Experience Client Regional Indemnity Weekend admissions 16 Weekend admission percent 59.3% 28.6% Weekend admission ALOS 3.2 4.5 Average weekend admission total 3,507 8,381 Average weekend daily paid 1,100 1,847 Average Length of Stay Experience - All Admissions Average length of stay 4.87 4.26 Average admission paid total 5,648 8,042 Average daily paid 1,160 1,890 Admission Total Paid Analysis - All Admissions Total Hospital Average 4,096 6,166 Professional fees Average 952 1,233 Other Expense Average 601 643 Utilization Cost/Savings Number Cost Additional days - client vs regional ALOS 23 $22,468 Admission Type Admissions ALOS Ave f/Adn Medical 16 4.6 3,952 Surgical 8 5.3 9,514 Pregnancy - Normal Delivery 7 1.7 3,636 - Cesarean Section 3 9.0 11,702 - Newborn 0 0.0 0 Mental - Psych 4 7.5 3,684 - Substance Abuse 0 0.0 0 1 /01 /96 - 12/31 /96 ABC COMPANY Page 11 Catastrophic Illness A catastrophic illness is defined as amounts in excess of $25,000 to a single individual for a single cause. Catastrophic illnesses totaled $119,938 , or 14.8% of medical claims. This total was incurred by 4 claimants, or 0.5% of the total. The PacifiCare norms are about 22.2% of the claims caused by about 0.5% of the claimants. The average paid per claimant was $29,985. The average PacifiCare catastrophic claim was $55,746. Catastrophic Illness Cases by Diagnostic Category: Average Paid Cause Claimants Days Payment per Claimant Tumors 1 10 38,684 38,684 Mental & Substance Abuse 1 28 27,411 27,411 Infections & Parasitic 1 19 27,118 27,118 Pregnancy & Childbirth 1 21 26,725 26,725 Total 4 78 $119,938 $29,985 Catastrophic Illness Cases by Relationship: Average Paid Relationship Claimants Days Payment per Claimant Employees 4 78 119,938 29,985 Catastrophic Illness Cases by Age Band: Average Paid Age Band Claimants Days Payment per Claimant 35-49 1 21 26,725 26,725 50-64 3 57 93,213 31,071 1 1 /01 /96 - 12/31 /96 ABC COMPANY Analysis Of Skeleton & Muscle System Page 12 Skeleton & Muscle System claims accounted for 17.2% of the payments in this period, and 9.7% of the claimants. Average Paid Relationship Claimants Days Payment per Claimant Employees 270 11 110,040 408 Spouses 29 0 14,209 490 Children 31 0 15,303 494 Total 330 11 $139,552 $423 Age Band Claimants Days Payment Ave Paid 1-19 28 0 15,253 545 20-34 25 0 7,733 309 35-49 142 6 59,669 420 50-64 132 5 56,731 430 65 and over 3 0 166 55 Leading Diagnosis Claimants Days Payment Ave Paid 722 INTERYERTEBRAL DISC DIS 14 3 29,172 2,084 724 BACK DISORDER NEC NOS 43 4 16,786 390 726 PERIPH ENTHESOPATHIES 37 0 12,698 343 715 OSTEOARTHROSIS ET AL 12 4 12,058 1,005 732 OSTEOCHONDROPATHIES 2 0 11,922 5,961 717 KNEE INT DERANGEMENT 18 0 11,216 623 719 JOINT DISORDER NEC NOS 46 0 10,523 229 714 RHEUM ARTH/POLYARTHROPAT 6 0 7,097 1,183 729 SOFT TISS DISORDERS OTHE 44 0 5,131 117 733 BONE/CART DISORDERS OTHE 20 0 4,845 242 Admission Type Claimants Days Payment Ave/Day Medical 1 4.0 4,746 1,186 Surgical 3 2.3 5,906 2,531 Total 4 2.8 5,616 2,042 1 /01 /96 - 12/31 /96 ABC COMPANY Page 13 Analysis Of Tumors Tumor claims accounted for 1 1.6% of the payments in this period, and 3.4% of the claimants. Relationship Employees Spouses Children Total Age Band 1-19 20-34 35-49 50-64 65 and over Leading Diagnosis 174 CA BRST F 200 LYMPHOSARC/RETICULOSARC 202 CALYMPHOID/HISTOCYTIC 218 LITER LEIOMYOMA 211 BENIGN DIGESTIVE SYSTEM 216 BEN NEO SKIN 155 CA LIVER INTRAHEPATIC BI 157 CA PANCREAS 238 NEO UNSPECIFIED SITES/TI 228 HEMANGIOMA/LYMPHANGIOMA Admission Type Surgical Total Claimants Days 1D4 12 6 0 5 0 115 12 Claimants Days 4 0 12 0 39 0 55 12 5 0 Claimants Days 8 0 1 0 1 10 10 2 5 0 28 0 2 0 1 0 13 0 4 0 Claimants Days 2 6.0 2 6.0 Average Paid Payment per Claimant 91,525 880 2,126 354 560 112 S94,211 $819 Payment Ave Paid 341 85 1,738 145 15,960 409 75,884 1,380 289 58 Payment Ave Paid 24,901 3,113 24,501 24,501 13,715 13,715 7,901 790 3,967 793 3,480 124 2,263 1,132 2,232 2,232 1,912 147 1,859 465 Payment Ave/Day 8,956 1,493 8,956 1,493 ,1 /01 /96 - 12/31 /96 ABC COMPANY Analysis Of Symptoms & Signs Page 14 Symptoms & Signs claims accounted for 11.4% of the payments in this period, and 21.0% of the claimants. Relationship Employees Spouses Children Total Age Band 1-19 20-34 35-49 50-64 65 and over Leading Diagnosis 780 GENERAL SYMPTOMS 789 ABD/PELVIS SYMPT INVOLVI 786 RESP SYS/OTH CHEST SYMP 799 UNKNOWN/ROUTINE 787 GI SYSTEM SYMPTOMS 788 URIN SYS SYMP 783 NUTRIT/METAB/DEVEL SYMP 784 HEAD/NECK SYMPT INVOLV 793 ABN FIND -BODY STRUCT NOS V70 GENERAL MEDICAL EXAM NOS Admission Type Medical Total Claimants Days 584 38 51 0 78 3 713 41 Claimants Days 68 3 37 0 279 0 301 38 28 0 Claimants Days 77 0 61 0 72 1 95 0 19 0 14 0 5 40 29 0 18 0 103 0 Claimants Days 3 13.7 3 13.7 Average Paid Payment per Claimant 69,901 120 11,213 220 11,747 151 $92,861 $130 Payment Ave Paid 11,141 164 3,133 85 38,253 137 37,039 123 3,296 118 Payment Ave Paid 12,840 167 12,739 209 11,354 158 8,555 90 7,551 397 5,740 410 5,076 1,015 4,281 148 4,178 232 3,616 35 Payment Ave/Day 7,307 535 7,307 535 MEDICAL MANAGED CARE PLANS (PPO. POS & EPO) FEE QUOTATIONS Please provide your fee quotation with regard to the services described in this section. Your fee quotation should be presented in the following format. Access Fee Additional Charges: ID Cards/Enrollment Start -Up Fees Other (detail) $ 2.04 (included in TPA Services) $ Included in TPA Services $ N/A $ N/A For purposes of your quote, please assume 605 eligibles in the PPO plans. U POS EPO Access Fee $ 2.61* $ 2.61* Capitation Fee $ * $ * Incentive $ 5.56 $ 5.56 Additional Charges: ID Cards/Enrollment $ * $ Start -Up Fees $ N/A $ N/A Other (detail) $ N/A $ N/A * included in TPA Services For purposes of your quote, please assume 80 eligibles in the POS plan and 585 in the EPO plan. How do the above charges differ assuming you are selected as the network provider for all plans? 1 /01 /96 - 12/31 /96 ABC COMPANY Analysis Of Mental & Substance Abuse Page 15 Mental & Substance Abuse accounted for 9.5% of the payments in this period, 5.8% of the claimants, and 16.2% of the room and board days. Psych claims were 97.9% of the total mental expenses, while substance abuse claims were 2.1 %. The expected norms for mental are 70% psych and 30% substance abuse. Adolescent mental expenses are 15.4% of the total, while the norm is 30%. PacifiCare has contracts in place in certain markets that provide Mental Utilization Review services. Your PacifiCare representative can review your situation to see if your experience might be a candidate for this service. Average Paid Relationship Claimants Days Payment per Claimant PSYCH Employees 141 28 62,563 444 Spouses 8 0 2,314 289 Children 41 2 11,016 269 SUBSTANCE ABUSE Employees 2 0 694 347 Children 3 0 936 312 Total 195 30 $77,523 $398 Age Band Claimants Days Payment Ave Paid PSYCH 0-12 10 0 1,855 185 13-18 20 2 5,257 263 19-59 149 28 66,182 444 Over 60 11 0 2,600 236 SUBSTANCE ABUSE 13-18 3 0 936 312 19-59 2 0 694 347 q 1 /01 /96 - 12/31 /96 ABC COMPANY Leading Diagnosis Claimants Days Payment Ave Paid 296 PSYCHOSES AFFECTIVE 27 16 26,041 964 309 ADJUST REACTION 55 0 17,470 318 300 NEUROTIC DISORDERS 43 2 13,338 310 311 DEPRESSIVE DISORDER NEC 31 0 7,371 238 306 PSYCHOPHYSIOLOGIC DIS 3 12 5,369 1,790 301 PERSONALITY DISORDERS 7 0 1,983 283 307 PSYCH SYMPTOMS OTHER 2 0 1,383 691 Admission Type Admits ALOS Ave Paid Ave/Day Psych 4 7.5 3,684 491 Total 4 7.5 3,684 491 Page 16 1 /01 /96 - 12/31 /96 ABC COMPANY Analysis Of Pregnancy & Childbirth Page 17 Pregnancy & Childbirth claims accounted for 9.5% of the payments in this period, and 3.2% of the claimants. Average Paid Relationship Claimants Days Payment per Claimant Employees 58 39 70,038 1,208 Children 51 1 7,145 140 Total 109 40 $77,183 5708 Age Band Claimants Days Payment Ave Paid Less than 1 5 0 918 184 1-19 46 1 6,227 135 20-34 20 11 21,062 1,053 35-49 38 28 48,976 1,289 Leading Diagnosis Claimants Days Payment Ave Paid 650 OB NORMAL DEL 7 0 19,992 2,856 656 FETAL PROB AFFECTING MGT 5 4 10,120 2,024 V22 NORMAL PREGNANCY 15 0 6,661 444 651 08 MULT GESTATION 3 1 6,355 2,118 6" THREAT ABORT 4 20 5,422 1,355 664 PERINEAL TRAUM W DELIVER 2 4 4,343 2,172 660 LABOR OBSTRUCTED 1 4 3,424 3,424 V20 HEALTH SUPRV IMF/CHILD 43 0 3,273 76 655 FETAL ABN AFFECT MOTHER 4 0 2,723 681 645 08 PROLONGED 2 2 2,307 1,154 Admission Type Claimants Days Payment Ave/Day Normal Del 7 1.7 3,636 2,121 C-Sections 3 9.0 11,702 1,300 Medical 1 1.0 1,062 1,062 Total 11 3.6 5,602 1,540 1 /01 /96 - 12/31 /96 ABC COMPANY Analysis Of Injury & Poisoning Page 18 Injury & Poisoning claims accounted for 8.4% of the payments in this period, and 7.2% of the claimants. Relationship Employees Spouses Children Total Age Band 1-19 20-34 35-49 50-64 65 and over Leading Diagnosis 844 SPRAIN KNEE 836 DISL KNEE 847 SPRAIN BACK 824 FX ANKLE 813 FX RAD/ULNA 845 SPRAIN OF ANKLE FOOT 996 GRAFT REPLACEMENT 633 WRIST DISLOCATION 816 FX PHAL HAND 854 BRAIN INJ OTH Ctaimants Days 160 0 15 0 70 0 245 0 Claimants Days 67 0 12 0 76 0 88 0 2 0 Claimants Days 13 0 7 0 37 0 3 0 4 0 15 0 2 0 1 0 4 0 4 0 Average Paid Payment per Claimant 37,068 232 17,114 1,141 14,332 205 568,513 $280 Payment Ave Paid 14,332 214 2,569 214 24,693 325 26,871 305 49 24 Payment Ave Paid 11,573 890 11,484 1,641 5,906 160 4,281 1,427 2,661 665 2,637 176 2,616 1,308 2,396 2,396 1,867 . 467 1,580 395 1 /01 /96 - 12/31 /96 ABC COMPANY Analysis Of Genitourinary System Page 19 Genitourinary System claims accounted for 8.3% of the payments in this period, and 10.4% of the claimants. Relationship Employees Spouses Children Total Age Band 1-19 20-34 35-49 50-64 65 and over Leading Diagnosis 592 KIDNEY CALCUL URETER 626 MENSTRAL DIS B ABD BLD F 611 BRST OTH DIS OF 583 NEPHRITIS NOS 610 MAMMARY DYSPLASIABENIGN 627 MENOPAUSAL DISORDERS 599 URIN TRACT/URETER DISORD 620 F GENIT NONINFL DISEASE 616 F GEN INFLAM DIS CERVIX/ 590 KIDNEY INFECTION Admission Type Medical Surgical Total Claimants Days 312 7 20 0 20 3 352 10 Claimants Days 15 3 25 0 166 2 138 5 8 0 Claimants Days 4 0 36 2 56 0 1 5 31 0 60 0 29 0 6 0 34 0 1 3 Claimants Days 1 3.0 2 3.5 3 3.3 Average Paid Payment per Claimant 61,442 197 1,815 91 4,372 219 $67,629 $192 Payment Ave Paid 4,078 272 5,605 224 36,100 217 21,409 155 437 55 Payment Ave Paid 10,504 2,626 10,456 290 9,550 171 6,619 6,619 5,670 183 4,263 71 3,903 135 2,497 416 2,488 73 2,397 2,397 Payment Ave/Day 2,757 919 6,092 1,740 4,980 1,494 No Text Sample Monthly Experience Summary Paclf Care'f' ABC COMPANY Monthly Experience Summary Date Liability Experience Capitation Specific Refund AdntitJOlher Fees Specific Prem Incentive 9601 313.499 95,913 153,814 0 6,473 1,247 638 9602 318,607 88.732 152,362 0 6,396 1,259 651 9603 318,607 132,953 154.362 0 6,396 1,261 651 9604 320,607 137,888 153,555 0 6,597 1,318 659 9605 320,276 141,397 152,555 0 6,647 1,314 656 9606 328,276 168.418 154,685 0 6,742 1,414 707 9607 321,404 175,389 153,811 0 6,577 1,372 658 9608 315.444 157.965 153,795 25,445 6,362 1,263 616 9609 308,442 185,922 153,744 3,636 6,255 1,225 592 9610 308,442 184,140 153,814 1,525 6,463 1,245 636 9611 313,341 155,040 153,744 1,505 6,455 1,238 625 9612 328,404 263,209 155,570 1,541 6,447 1,276 643 Grand Total 3,815,349 1,886,966 1,845.811 33,652 77,810 15,432 7,732 Unused Liability $116,224 Expected Claims $3,052,279 Actual Claims = 121.2 % of Expected Claims Self Fund 125 Thursday, September 11, 1997 Specific Reimbursement S50,000 Aggregate: Annual Premium $8,000 Aggregate: blip i n nt.animal Liability $2. 000, 0011 Prepared by B. Mo smatt EPO Total £PO PPO Total PPO Date Liability Experience Capitation Specific Adndn Specific Incentive Single EE + I EE + 1 Fundly Funding Fees Premium Contracts Contracts Contracts Contracts 9601 300.000 87,555 153,814 0 5,280 1,132 580 150 36 25 175 9602 305.000 78,595 152,362 0 5,179 1,146 595 155 37 24 177 9603 305,000 122,555 154,362 0 5,179 1,148 595 155 37 24 177 9604 307,000 127.111 153,555 0 5,380 1,205 603 157 38 27 181 9605 307,000 131,554 152,555 0 5,380 1,205 603 157 38 27 181 9606 315.000 158,362 154.685 0 5,505 1,305 654 161 41 31 187 9607 308,000 163,489 153,811 0 5,345 1,254 600 159 39 26 183 9608 302,000 146,336 153,795 25,445 5,175 1,154 563 153 33 24 179 9609 295,000 175,523 153,744 3,636 5,055 1,112 536 150 31 23 178 9610 295,000 173.251 153,814 1,525 5,213 1,132 580 150 36 25 175 9611 300.000 143.844 153,744 1,505 5,205 1,125 569 148 35 25 173 9612 315,000 248,223 155,570 1,541 5,185 1,158 585 151 37 26 177 3,654,000 1.756,398 1,845,811 33,652 63,081 14,076 7,063 Date Liability Experience Capitation Specific Adman Specific Incentive Single EE + I EE + 1 Family Funding Fees Premium Contracts Contracts Contracts Contracts 9601 5,344 4,836 0 0 518 115 58 15 3 2 17 9602 5,385 4,515 0 0 522 113 56 14 3 2 16 9603 5,385 4,355 0 0 522 113 56 14 3 2 16 9604 5,385 3,622 0 0 522 113 56 14 3 2 16 9605 5,222 2,521 0 0 512 109 53 13 2 2 16 9606 5,222 3,345 0 0 512 109 53 13 2 2 16 9607 5,350 5,345 0 0 537 118 58 15 3 1 18 9608 5,222 5,785 0 0 512 109 53 13 2 2 16 9609 5,287 4,755 0 0 525 113 56 14 3 2 19 9610 5,287 4,978 0 0 525 113 56 14 3 2 19 9611 5,287 5,174 0 0 525 113 56 14 3 2 19 9612 5,350 8,810 0 0 537 118 58 15 3 1 18 63,726 58,041 0 0 6,269 1,356 669 DENTAL Total DENTAL ABC COMPANY Monthly Experience Summary ABCo0 PM099999 Date Liubiliv Experience Capitation Specific Admin Specific Incentive Single EE + 1 EE + 2 Family Funding Fees Premium Contracts Contracts Contracts Contracts 9601 8,155 3,522 0 0 675 0 0 172 39 33 197 9602 8,222 5,622 0 0 695 0 0 175 40 33 199 9603 8,222 6,043 0 0 695 0 0 175 40 33 199 9604 8,222 7,155 0 0 695 0 0 175 40 33 199 9605 8,054 7,322 0 0 755 0 0 181 40 31 203 9606 8,054 6,711 0 0 725 0 0 178 38 32 199 9607 8,054 6,555 0 0 695 0 0 175 40 33 199 9608 8,222 5,844 0 0 675 0 0 172 39 33 197 9609 8,155 5,644 0 0 675 0 0 172 39 33 197 9610 8,155 5,911 0 0 725 0 0 178 38 32 199 9611 8,054 6,022 0 0 725 0 0 178 38 32 199 9612 8,054 6,176 0 0 725 0 0 178 38 32 199 97,623 72,527 0 0 8,460 0 0 MEDICAL MANAGED CARE PLANS (PPO. POS & EPO) QUESTIONS TO BE ANSWERED You are required to respond to all of the following questions. Each question must be answered in detail. Reference should not be made to a prior response nor should an overall response be used to answer more than one question. Each question has been written to address a specific area of concern and not general concepts of preferred provider organizations and their operation. A complete answer to each question is required even when such answers may appear repetitious. Note: Unless otherwise specifically noted in your proposal, we will assume that the responses to the following questions apply to all in -network plans. For any question that this is not accurate, your proposal should clearly state to which plan the response applies. Your proposal shall provide responses for all plans. A. Organization 1. Please provide the names and positions of officers and board members, and whether they represent any hospital, physician medical association, or other interest. The structure of the Board of Directors is as follows: Officers: Jeffrey M. Folick, Chairman of the Board Wayne B. Lowell, Chief Financial Officer Coy F. Baugh, Treasurer Joseph S. Konowiecki, Secretary Directors: Eric D. Sipf John T. Kennedy Michael T. McDonnell M. Eugene Sherman, MD Jeffrey M. Folick Wayne B. Lowell Linda M. Lyons, MD Colorado Medical Director Leigh Truitt, MD 2. Please indicate the person(s) who would be the liaison to the City. Christine Lawrence, Account Manager Direct line: (303)714-3463 Toll free: (800)877-6685 extension: 43463 Fax number: (303)714-3999 Customer Service: (800)877-9777 3 Sample Large Claims Report SAMPLE LARGE CLAIMS REPORT GROUP Claims over S15,000 October 1, 1994 - September 30, 1995 Paid Claims I Primary Diagnosis I Comments Male S 128,643 Lymphomas Cancer of testes and bone. Hypertensive. Additional large claims expected. Female S112,031 I Chronic Renal Failure Additional large claims expected. Female S 78,891 Kidney Failure On dialysis. Additional large claims expected. Female $72,574 CABG Possible additional claims. Female S 60,409 Kidney Failure On dialysis, Additional large claims expected. Female S 46,048 Decqsed, Female S 45,744 Uterine Cancer Also has had colostomy. Additional large claims Female S 44,775 End Stage Renal Disease Awnitinot kidney lam. Male S 43,441 Lung Cancer Also has diabetes. Additional large claims expecte& Male S 39,237 Brain Cancer Also has had pulmonary embolism, acute myocardial in5rction. Additional large claimsexpected. Male S 37,511 Leukemia, Multiple Mveloma High claims expmed. Female S 32,479 Heart Valve Replacement Also has diabetes. Male S 31,492 Heart Disease Female S 30,305 Uterine Cancer Also cancer of intra- abdominai area and colon. Additional large claims expected. Female 321,385 Lung Cancer Also has congestive heart failure. Additional large calms expected. Male S 18,402 Ruptured Appendix with Also has skin cancer. Peritonitis Male S 15,950 Asthma Potential for additional claims. Female S 15,070 Atrial Fibrillation and Also has congestive heart Cerebral Infarction failure. Sample Lag Study SAHPI LAG STUDY CI. AIMS IBNN S1UDY AS OF 294e496 WIS 1102AL PAID BY COMPLETION TOTAL ADJUST. ADJUSTED AR)N111 Oy1f PERCENT EST EXPENSE MENT TOTAL IBNR l'IIRNFNT MU 1211AN 14 NI Y MEMBERS PMPM PMPM AVL: JANUARY% 1•,IM 70,9/1 lf1)6 226,144 p06.1441 120.110 109.910 2A02 wm Sum I N.CEMtlkR 9f 10•,7p 2979% 67%% 1.1,11/ 1p/y9 (61,Ilq 120,790 411,779 2.411 NIIVLMtlkR 9S UII1 . 07lH IS•,261 , 1,1 I36,42 10.991 2,190 SSOo W 11,32% 01,491 • "All 9,125NlNER 2.149 Sim011 U212, Sk PIE61BER 9s I14,I36 9096% 1111.341111 • I'll? 2.299 1675 AIkWS195 Ip.10/ Mll% 107,903 6 II5,340 1.111141 2,101 SOOs IIII.Y 95 67.00 9900% p,111 0 103,963 07,411 6% 2.271 IS % 4101 It ONE 95 11,793 !l.0f% N,100 • M,00t 351 111 7.1M 1814 MAY 9f 11115,727 9l 11% 111116.41143 • 2/6,11413 717 i,271 3.119 )9 12 APNII. 95 I410,119 99.096 141111.4111 • 140.411111 161 2.101 9102 es 9f MAR1'II95 137.1111113 9.91% Ill.= • 127.005 Is 1,175 60" S1/S H USIUARY 9% IANUARY 9S 1611,91s M.93% 109.110 • 1•f.101 7• 2A16 U 70 S/ 91 77,191 9991% 77,9311 • 77.971 K 2.441 ]19] DI:11MBL111 91 121,1191 9991% 12/.7M • 111,7N M I'M $916 MIVEMBEA% UCIOBE % 61.6% 9997% 61.717 0 61.717 21 1.406 11" 2700 I9.910 9997% 19,999 • 1l,ri9 6 1,416 1109 SE PfEMBER 91 31,071 IM 011096 11.871 0 71,17! • 1.110 1102 AUGUST91 HOLY 91 169,671 1••10% 161.670 • IM,67/ • 1.444 III SI 72 46 /6.66011 IM 0/% 46.60 • I6,N1 • I,IN 1t 10 JIINI 91 90,•f7 IM Oft 96.057 • 91.•f7 • 1.449 6767 MAY 91 APRIL 91 60,591 IM 0111116 N.591 0 6i,S91 • 1,1f6 17II SU If N,773 IM"% )931) • 39.7)) • 1.462 2707 MANCII% 112,426 IM 00% 112.426 8 112.126 0 1,474 762) fEBRUARY91 JANUARY94 14.712 141111114111111% 34,711 0 34,712 • 1,16f 1169 2270 )],119 IM 0•% 37,119 • 33,119 0 I./N lift DLCEMBER 91 20,1N IM 01191, 21.764 • 20,761 • 1.J61 Iasi NOVEMBER 97 OCIOOER ri 311,011 IM••16 3111.0141 • Am • 1.117 1240 2901 20.031 I••••% 26,051 • 26.0% a 1,171 Otis SE PFEMBER 93 "."1 In"% 79M • "."1 • 1,127 I110 AIN:UST93 Aft 97 16,601 IM a•% I6,6N 0 1401 • I.ril ]I 50 317S 30,616 IM1•% 11,616 • 3111,6K • 1.IMI is 11 111NE 93 96.5111 low% 96.91/ • 96,91111 • 1,161 4140 MAY91 APNII 91 18,171 IM ••76 10,171 0 11,173 0 1, NA 1127 11946 MARCH 93 1.1.171 IM 1•% 1101,11111 • 1.1,1f• • 1.311 7526 PRIOR 327.406 IM•1% 317,406 0 327,/00 0 1.121 24721 1,857.793 __ --- --------- __... _ 3.463.896 .... �__.._ (221,010) 1,279,106 101,I9) IBNR. 101A1 I.IAIIILI fY AS OF 29-1,e16-96 111,293 LkSS PAYAtl1.LS 0 DOTAL IBNR II) KWURD - -----_ 111,21] page 1 No Text No Text PacifiCare ° NCQA Awards PacifiCare of Colorado Full Accreditation PacifiCare of Colorado, formerly FHP Health Care, has been awarded Full Accreditation by the National Committee for Quality Assurance (NCQA), an independent, not -for -profit organization that evaluates managed care organizations. Full Accreditation is granted for a period of three years to health plans that have excellent programs for continuous quality improvement and meet NCQA's rigorous standards. It is the highest level of accreditation status awarded by NCQA. Why is NCQA accreditation important? The NCQA accreditation process is an evaluation of how a health plan ensures its members are receiving high -quality care. NCQA reviews rigorous on -site and off -site evaluations conducted by a team of physicians and managed care experts. A national oversight committee of physicians analyzes the team's findings and assigns an accreditation level based on the health plan's performance compared to NCQA standards. There are approximately 50 NCQA standards in the areas of quality improvement, physician credentialing, member rights and responsibilities, !• G E D preventive health services, utilization management and medical records. d Cy t FULL What does PacifiCare's Full Accreditation mean to me? ACCREDITATION Rigorous review by NCQA ensures that health plans, such as NCQA PacifiCare, are held accountable for the quality of care and service they deliver. As a recipient of NCQA Full Accreditation, PacifiCare of 0 •�Cfj - Colorado has demonstrated its commitment to creating an environment 'Q �, (r ♦O of continuous quality improvement. gN[Zp� EMOSO41.00 IGM7 ENGLEWOOD, Colo. — PacifiCare of Colorado earned the 1998 Sachs Seal of Excellence, identifying it as one of the top health plans in the nation for member services, according to Sachs Group, an independent health care information company. The Seal of Excellence awards, now in their third year, annually recognize a select group of health plans rated superior in their markets by their members. PacifiCare of Colorado is one of only 16 plans nationwide selected for the Seal of Excellence. "This award is particularly important to us because it means that our members feel that PacifiCare of Colorado has served them well," said Eric Sipf, president and chief executive officer of PacifiCare of Colorado. "We are honored to be recognized in this way, and we will continue to strive to surpass our members' expectations." The basis for the award is Sachs/Scarborough HealthPlusTM research conducted in 30 major markets including more than 97,000 consumers. To reflect consumers' local health care attitudes, plans were compared to local market averages rather than a national average. Using this research, health plans across the country were judged in member loyalty and member services. PacifiCare of Colorado has earned the Seal of Excellence in the member services category. "The plans earning the Sachs Seal of Excellence for member services have made outstanding achievements in satisfying their members," said Bob Mayo, senior vice president of Sachs Group. "In today's competitive market, these plans truly understand the importance of member services and its impact on customer retention." Sachs Seal of Excellence Page 2 Plans winning the member services award were analyzed based on the following key measures: • Handling claims and billing quickly, courteously and accurately • Handling of written and phone inquiries • Cost members pay to belong to our plan • Out-of-pocket expenses for our members • Value of coverage, considering what members pay • Explanation of benefits to members • Availability of information to our members about eligibility, covered services and administrative issues • Availability of information to our members about the costs of care • Time our members spend filling out forms or other paperwork PacifiCare is one of the largest health plans in Colorado, with approximately 400,000 members statewide. PacifiCare's Medicare risk program is Secure Horizons. Based in Santa Ana, Calif., PacifiCare Health Systems is one of the nation's leading managed health care services companies. Primary operations include managed care products for employer groups and Medicare and Medicaid beneficiaries in I 1 states and Guam, serving nearly 3.8 million members. Other specialty managed care operations include life and health insurance, behavioral health services, workers' compensation, dental and vision services, pharmacy benefit management and Medicare -risk management services. Sachs Group is the acknowledged leader in providing the health care industry with strategic information, current market intelligence and analysis, industry benchmarks, custom segmentation, and database marketing services. Sachs' innovative solutions help clients leverage information to facilitate short- and long-term growth and profitability. eking Charge of Your Healthsm Health information foryou and your family Healthwise Knowledgebase TM The Healthwise KnowledgebaseT" is a quick, easy way for you to find health information. Developed by medical experts and written in consumer -friendly language, this resource contains 27,000 pages of health information, including: 1 Information on 500 health problems 1 Answers to 600 questions about medical tests and procedures 1 Information on 500 self-help and support groups An electronic drug reference that includes 8,000 medications Easy as 1-2-3 To access the Knowledgebase, simply: 1. Go to www.pacificare.com/colorado (you can also reach this site through www.pacificare.com) 2. Click on the Taking Charge of Your Health icon I Type in your member ID number, including the two -digit suffix, and your ZIP code. (This information is on your PacifiCare member ID card.)* Questions? Call the PacifiCare Service Center at 1-800-877-9777. *PacifiCare will not monitor your use of this system in any way, and your viewing of this information is strictly confidential. Your member ID number is required to ensure that the Knowledgebase is available exclusively to our customers, and to meet certain licensing requirements. 980411 ewe 3. What is your network's service area? REGIONAL SERVICE AREA Adams Denver Huerfano Lincoln Arapahoe Douglas Jefferson Logan Bent Elbert Kit Carson Morgan Boulder El Paso Kiowa Otero Cheyenne Fremont La Plata Park Clear Creek Gilpin Lake Phillips Crowley Grand Latimer Pueblo Please see Network Service Area attachment for map. Sedgwick Summit Teller Washington Weld Yuma 4. How many enrolled groups and total number of enrolled participants participated in your managed care plan during the most recently completed quarter? During the same quarter last year? Membership as of second quarter 1998: 408,703 Membership as of second quarter 1997: 387,776 5. What is the projected enrollment for the next fiscal year? Projected membership as of January 1, 19" is 407,693 6. Will you provide client specific directories to the City, at no cost, for employee distribution? If no, will you agree to provide directories on diskette to the City for internal production? PacifiCare does not provide client specific directories. PacifiCare currently has a hard copy directory and a world wide web site at www.pacificare.com. This site offers members the ability to access the provider directories on line. 7. How often will you update your directories? What is the turn -around time for getting these updated directories to the City? Provider directories are updated monthly on the PacifiCare's web site, at www.pacificare.com. Hard copies are revised and published twice a year. Although directories are typically distributed once a year during enrollment, PacifiCare will gladly provide directories at any time, at the request of the employer group or participant. 8. Please provide sample utilization reports readily available for clients. How often are they produced? Is there a charge? If so, please state the charge. PacifiCare provides a comprehensive reporting package for self -insured groups and those who are experience rated which includes: • Sherlock reports which provide detailed information on demographics, paid claims by diagnosis categories, and network utilization. Sherlock reports are provided quarterly. 4 PacifiCare Behavioral Health I There's Help When you (1-888-777-2735) at Need It. any time, you can receive a confidential referral There may be times in directly on or after your life when you find January 1, 1998. Your yourself feeling out of primary care physician can also request a control. Maybe it's a referral on your behalf family conflict. Or maybe it's a stress -related by calling PBH directly. problem. Or perhaps you could be struggling with How to Access Your an alcoholic addiction. Benefits Whatever the problem, you don't need to handle To access your behavioral it alone. We can help. health benefits, call PBH Your health care partner, directly at our toll -free PacifiCare of Colorado number, which is and PacifiCare Behavioral available 24 hours a day. Health can provide you When you call, you'll with the support you need speak with an intake to weather the storm. coordinator who'll check your eligibility, gather PacifiCare Behavioral basic demographic Health (PBH) specializes information and help in providing behavioral determine the type of health care. You benefit service you need. A to several ways by clinical interviewer will receiving your behavioral then talk to you in detail health care benefits about the problem that through a company you're experiencing and specializing in behavioral assess what provider and health. First, because of treatment would be best our strict provider for your situation. If credentialing process and you're referred to a PBH ongoing evaluations, you provider, you'll be can feel good about the authorized for a specific quality of care you'll number of visits or a receive. Also, we take the specified period of time. guess work out of finding a behavioral health We Select Our provider and can match Providers Carefully your specific needs with the appropriate provider. All of our providers are And since, you can call carefully screened and PBH's toll -free number meet extensive licensing, accreditation and program Questions and PBH -- A Leader in requirements. They Answers Behavioral Health Care include contracted hospitals, residential Is pre -authorization If you need to access your treatment centers, always necessary to start behavioral health benefits, outpatient chemical a treatment program? you want to feel good dependency programs and about the company providing individual professionals yes, all benefits must be them. throughout Colorado. pre -authorized by PBH. If you do not go through Here are just a few of our PBH, no benefits will be qualifications: We Maintain paid — except in an Confidentiality emergency. We are a wholly owned subsidiary of PacifiCare With PBH, you can be Health Systems, one of the assured that what you How long does it take to nation's most respected discuss with our intake get an appointment? and financially stable coordinators and managed -care organizations. interviewers is kept The Standards we set with We are a behavioral health strictly confidential. We our providers are: care company that is here provide information only for the long term. to the professionals • Routine Referrals: • We've been serving the delivering your treatment. 95% of members receive behavioral health care needs Confidentiality is built an appointment within 5 of organizations since 1986 into the operations of business days. and our employee assistance PBH through a system of • Urgent/Emergent program has been helping control and security that Referrals: All members employers since 1975. protects both written and receive treatment within • We serve a combined computer -based 24 hours. Inpatient membership of 2 million information. admissions should occur members in a variety of immediately. industries. What happens in an emergency? In an emergency, our first concern is for your health and well-being. Get to a treatment center first, then, as soon as possible (or within 24 hours of admission), call PBH at our toll -free number, 1-888-777-2735. 'i pMfomd PacifiCare ° PacifiCare Review, your utilization review program for PPO and indemnity plans, can help you become a wise health care consumer. It guards against overspending health care dollars, making sure you are receiving treatment that is necessary and appropriate. Make the most of your benefits by knowing what is required BEFORE you receive medical care or treatment. This is especially important for services that require your doc- tor to call Utilization Review BEFORE the treatment or service takes place. Benefits may be reduced and/or an additional deductible may be applied.* It is your responsibility to make sure preauthorization is done prior to the following: Hospital Admissions (includes Skilled Nursing Facility stays and Inpatient Rehabilitation) Outpatient Surgeries performed in other than the doctors office PacifiCare Review 1 Home Health Care 1 Inpatient and Outpatient Hospice Care Please be sure to call at least five days before you are to receive these services. For maternity cases, it is recommended that a call be made to PacifiCare Review as soon as pregnancy is confirmed. For emergency or urgent hospital admissions, the call must be made within 48 hours or on the next business day if the admission is on a weekend, holiday, or after 5 p.m. on Friday. Call toll -free, 1-800-255-1189. Certification of utilization review does not guarantee benefits or that all charges are covered under the policy. Charges submitted for payment are subject to all terms and conditions of the policy. *Failure -to -Call Penalty: Certification must be obtained before services are received. If the Insured Individual fails to call PacifiCare Review as required, a penalty of an additional deductible of $250 will apply. This penalty is in addition to any other deductible under the policy and will not apply toward the satisfaction of a deductible, copayment or stop -loss. 6455 South Yosemite Street Englewood, CO 80111 Taking a 3�0 0 G SHIFTING PERCEPTIONS A so PaC1.fiCare® I June Copyright®1998 PacifiCare of Colorado The HMO model of bealtb coverage has revitalized patient care, physician practices and compensation, quality measures and economics. THE REINVENTION OF HEALTH CARE Over the last two decades - and particularly over the last five years - managed care has reinvented health care as we know it in the United States. Health insurance 20 years ago focused on taking care of people when they were sick. But a new focus on preventive measures, in tandem with skyrocketing health care costs, gave birth to the system we now know as managed care. As other industries have done, managed care sought to streamline an inefficient industry to achieve a better quality "product" - in this case, medical care - while retaining a reasonable profit. The strategy: focusing on caring for people from the beginning - attempting to prevent behav- iors or diagnose conditions that could cause illness, before people begin to suffer - and enlisting the support of physi- cians, employers and patients themselves. The reward for purchasers: heightened, measurable quality health care at lower cost. While many people, including much of the media, tend to glorify "the good old days" of medicine in the "Marcus Welby, M.D.," era, the good old days really weren't so good. A recent William M. Mercer, Inc., report to the American Association of Health Plans, written by health care industry scholar Michael L. Millenson, reminds us why Americans turned to managed care in the first place. Medical expenses had been skyrocketing during the 1960s. The cost of a day in the hospital rose by 7 percent per year between 1963 and 1966. It increased 13 percent per year from 1966 to 1969. Millenson quotes Fortune magazine on the state of American medicine in 1970: Mucb of U.S. medical care, particularly the everyday busi- ness of preventing and treating routine illnesses, is inferior in quality, wastefully dispensed and inequitably financed.... Most Americans are badly served by the obsolete, over- strained medical system that has grown up about them helter-skelter... the time has come for radical change. "' In 1973, the federal Health Maintenance Organization Act began to bring about that change. The HMO model of health coverage has revitalized patient care, physician practices and compensation, quality measures and economics. With these changes, we believe, comes the critical responsibility of sharing information about how health plans work with customers, provider partners and communities. In the following pages, we'll explore what managed care means to the medical system and how it has affected health care cover- age in the United States and particularly in Colorado. PacmQ L G MANAGED CARE'S EFFECTS ONTHE HEALTH CARE MARKETPLACE Managed care truly has overhauled the entire U.S. health care system. Whereas old-style fee -for -service insurance left health care fragmented into individual cases, managed care combines the individual perspective with a broader view of each physician's practice, each company's employees and each community in which a health plan offers coverage. Prevention and Wellness HMOs (also called health plans in this document) turned the spotlight on preventive care and wellness when they were introduced on a broad scale during the 1970s. Since that time, the concept of preventive care — regular physical examinations, screenings for cancer and other illnesses, questionnaires about family medical history— has become familiar to most of us. Health plans have several reasons for this focus: • Quality of care. When physicians see patients on a regular basis, they can establish a relationship and become familiar with a patient's background, risks In an HMO, the health plan, and health concerns. physician and patient all are • Health management. HMOs can identify patients at working toward the same risk for or suffering from particular ailments, then goal.• keeping the patient as share this information with doctors so patients can healthy as possible. receive appropriate treatment. • Alignment of incentives. In an HMO, the health plan, physician and patient all are working toward the same goal: keeping the patient as healthy as possible. A Responsibility for Quality Care Fee -for -service health insurers seldom were held account- able and, thus, rarely examined their impact on health further than their own bottom line. HMOs, on the other hand, use a variety of tools to examine the health care they offer: • Quality measurement giver HMOs a way to make sure they practice what they preach. From internal reviews of screening and utilization statistics to external audits and certification, HMOs know what services their members should be receiving and what can be done to improve the care members receive. • Data tracking includes using sophisticated technol- ogy to keep track of information about thousands of plan members' health, including how many members have certain healdz conditions and whether some conditions are increasing at an unusually rapid pace, indicating that the plan should take specific action to P cffiGame prevent them. 2 • Physician credentialing means HMOs check the backgrounds and records of physicians they hire or contract with, to ensure that they have solid reputations and that the plan can reasonably assume they will provide members with high -quality health care. Slowing Medical Cost Increases We cannot ignore the fact that cost is a primary consider- ation in purchasing health care coverage. Most small- business employers select coverage based on cost, and as health costs increase, the number of people who lose health coverage increases correspondingly. The increasing number of legislative mandates on health care is not helping this unfortunate trend. Even mandated benefit or policy drives up the cost of health care, because plans must increase resources to implement new regula- tions. And, more importantly, with mandated benefits, the actual cost of care rises. Those kinds of increases are unac- ceptable at a time when the numbers of the uninsured are reaching new heights. A recent study by The Lewin Group, a prominent health policy consultancy firm, found that for every 1 percent increase in national employer premiums, the number of people without health coverage will increase by 400,000.2 It is very significant, then, that while HMOs have worked to ensure that members receive the care they need, they also have been making health care more affordable. The HMO system is growing in popularity with Colorado employers and consumers: In 1996, 47 percent of Coloradans with commercial health coverage belonged to HMOs, and fully 82 percent of Coloradans with commercial health coverage It is very significant, then, received care through some type of managed care plan.3 that wbile HMOs have Those numbers are growing. Nationally, HMO membership worked to ensure that has increased by 85 percent since 1990, going from 36.5 members receive the care million to 67.5 million in 1996.` they need, they also bave been making bealtb care Not coincidentally, increases in the cost of health care more affordable. coverage have slowed. Between 1991 and 1997, the rate of increase in the cost of HMO premiums for firms with more than 200 employees slowed from 12.1 percent to 2.0 per- cent. Employers with 10 or more employees paid 15 per- cent less per active employee for HMO coverage than for traditional health insurance in 1996.5 Even so, cost pressures continue to increase. Many HMOs face the prospect of raising premiums in 1999 to cover rising medical costs and mandated benefits and regulations. The issue of affordability has been tamed somewhat by HMOs over the past two decades, but the beast has not jj3LjCfflQ4jW® been conquered. 3 Health management in action ... PacifiCare's congestive beart failure management program tracks members who have been discharged from the hospital with congestive heart failure. A nurse case manager establisbes regular telepbone contact with these members and their doctors, checking that they are taking their medication regularly and understand the symptoms of their disease and the importance of seeing their doctors. These simple measures have helped lower the 90-day bospital readmission rate for PacifiCare members who have suffered congestive heart failure by 11 percent during a one-year trial. COORDINATED CARE MEANS APPROPRIATE, AFFORDABLE MEDICAL SERVICES HMOs emphasize providing patients with the right care, at the right time, in the right setting. They also work to ensure a patient's providers are working in concert, rather than flying solo. The philosophy of coordinated care relies on communication among members, physicians and the health plan. The success of coordinated care is predicated upon members building ongoing relationships with their primary care physicians (PCPs). When members need care their primary physician cannot provide, they obtain a referral to a specialty physician. The referral process ensures that the PCP is aware of the treatment and that the health plan can track utilization and effectiveness of that treatment. Another way health plans work to coordinate members' care is through health management programs. Many HMOs initially assess a member's risk for certain health problems, such as heart disease, stroke or diabetes, due to heredity or lifestyle. Then the plan might work with members and physicians to develop a prevention or treatment plan and help members receive the care they need. The health management approach has another benefit: It allows HMOs to manage risk, where fee -for -service insurance avoids risk. This policy eliminates risk to members who are forthcoming about their family medical history, illnesses or other chronic conditions. Members of HMOs can be honest with their physician and health plan about their health status without worrying about "pre-existing conditions" being excluded from coverage. This important change opens access to health care for many individuals who otherwise might miss out on the preventive medical services that can best manage their health care. Health plans offer other health care tools to members as well. Some plans bring health education to the workplace through programs such as self -care seminars, handbooks and online resources. These programs help employees learn how to treat minor problems and understand when a health concern should be treated by a health care profes- sional. Newsletters and other communications devices keep members continually informed about how to improve relationships with physicians and describe symptoms clearly to enhance the care they receive. PacifiCaree 4 Health plans put quality QUALITY AN ESSENTIAL ELEMENT OF assurance into action in MANAGED CARE a number of ways. A few programs PlacifiCare A key improvement managed care has brought to the prac- uses include. tice of health care is quality measurement. With fee -for - service health insurance, members, regulators and plan • Reviewing quality, executives found it difficult to measure the care provided to from patient members, and especially to measure the health of the mem- satisfaction to the ber community as a whole. Physicians and health plan staff services physicians could not easily determine how many members suffered provide to members. from diabetes or heart failure, or whether female members • Constructing a had their mammograms each year. pharmacy formulary system that allows us As the United States attempts to track the health status of its to be certain we cover citizens with measures such as "Healthy People 2000," a set the medications that of standards for immunizations and screenings, quality will safely and assessments become increasingly important. g y effectively treat our members' healtb For HMOs, the importance of quality improvement pro - issues in a cost- grams is not just a novelty; most health plans have always efficient manner. believed quality assurance to be imperative to their opera- • Investing intensely in tions. Quality programs and cost-consciousness go hand in information hand. Cost -containment strategies such as coordinated care, tecbnology to allow pharmacy formularies and referral processes created an us to track members' opportunity for HMOs to track and measure the amount and health care, health kind of care patients received. Additionally, trimming some status and medical of the fat from health care — such as reducing unnecessary service utilization as surgeries — benefits patient health as well as purchasers' a group or by various pocketbooks. segments. • Motivating employees, HMOs' quality efforts pay off: Recent reviews of research through bonuses and studies on managed care found that most quality -of -care incentive programs, results were favorable to HMOs or showed similar quality of to help build a care compared with fee -for -service insurance.b culture of quality and innovation. On an individual level, HMOs generally do an excellent job of providing regular tests and screenings to members: • A National Committee for Quality Assurance report on managed care quality found that, during 1996, more than 70 percent of women in the appropriate age ranges received breast cancer and cervical cancer screening. Eighty-five percent of pregnant women received prenatal care in their first trimester. More than 65 percent of children had received appropriate immunizations by their second birthday.' • Medicare HMO enrollees were more likely than fee - for -service beneficiaries to have received a mammo- gram -during 1995 — with 62 percent of HMO mem- bers vs. 39 percent of fee -for -service beneficiaries.8 • A study conducted by the Health Care Financing JDC0JCfflQ"® Administration found that Medicare HMO patients 5 Managed care's success depends on the relationships health plans maintain with members and physicians. Phcffl a C were diagnosed at considerably earlier, and therefore more treatable, stages than fee -for -service patients for four types of cancer: breast, cervix, melanoma and colon. Among elderly women with breast cancer, 72.3 percent of Medicare HMO patients had their cancer diagnosed at the two earliest stages, compared with 66 percent of fee -for -service patients.' While HMOs have developed rigorous quality measurement standards, the jury is still out on whether these measures can help informed consumers select among competitive health plans — and whether employers are willing to pay for superior quality. Over the last few years, numerous quality "report cards" have sprung up to compare HMOs' performance on certain quality standards, yet no single, comprehensive report card exists. Myriad report cards are published by organizations from the federal Health Care Financing Administration to Glamour magazine, making it difficult to glean valuable information. Studies sometimes compare different types of health plans or use questionable methodology to build a comparative chart. HMOs have been among the most vocal supporters of report cards, because they are one way for consumers to sift through the mass of information about health care — but without clear standards and comparability, report cards have little meaning. Much of the final verdict on quality initiatives rests with the employers that purchase most health care in the United States. Some large companies have begun to steer employ- ees toward "benchmark" health plan options by paying a larger percentage of employee premiums for plans that link quality and affordability1* Many employers, however, pur- chase health plans solely on cost — losing the big -picture view that is essential to a sound health care industry. PHYSICIAN RELATIONSHIPS: THE CORNER- STONE OF MANAGED CARE Managed care's success depends on the relationships health plans maintain with members and physicians. Health plans exist to offer health coverage; physicians provide the medi- cal care. To enable medical staff to do their jobs well, HMOs work closely with physicians to help them provide quality health care to members. Smoothing Plan Processes Most health plans handle specialty medical care through a referral process, which helps -physicians stay up-to-date about the care their patients receive. The process also ensures that primary care physicians have recommended the specialty care, and it confirms that the specialty care a member 6 • Monthly Experience Summary (MES) which provides a roll -up of plan expense by month, as well as tracks claims liability for self -insured groups if re -insured by a PacifiCare re -insurance partner. • Large Claims Report, which identifies claims over a set amount. This report may be provided quarterly. • Lag Study, which assists self -insured groups in establishing reserves for incurred but not reported claims (IBNR). This report is provided annually. There is no charge for these standard reports. Please see Sample Utilization Reports Attachment for sample reports. An annual HEDIS report will be provided to clients upon request. 9. Describe recent network provider utilization experience for the following: 1997 Data a. lab procedures per office visit; 19.35 % b., x-rays per office visit; and 11.37 % C. C-sections, as a percent of total deliveries. 15.8 % 10. Are there any "restructuring" plans for expansion or reduction of the network over the next 18 months? Please specify. Our contract with the Greeley Medical Center physicians could terminate as early as October 1, 1998. We are working with the practice to resolve differences to hopefully renegotiate a contract. 11. Please enclose all pertinent materials regarding your network and managed care services. Please see Managed Care Services attachment. 12. Will you agree to allow the City to omit providers from your existing network? Contract directly with network providers? Contract directly with non -network providers? No, PacifiCare does not allow clients to omit providers from the existing network, or contract directly with providers. 13. Please indicate the person(s) who will be the liaison to the City. Include resume. Christine Lawrence, Account Manager PacifiCare of Colorado Chris Lawrence has been in the managed health care business since 1988 beginning with four years at Lincoln National where she worked in various departments, including Enrollment/Billing and Sales/Service. More recently, Chris was employed by Great -West Life where she was a Service Representative offering support to her clients in the areas of health care, 401(k), and Flexible Spending arrangements. 5 receives will be covered by the health plan. The referral pro- cess is intended to work quickly and smoothly. The physician decides, in partnership with the patient, which specialty physi- cian will be best able to care for the patient's medical needs. The health plan checks that the service is covered by the patient's plan and tracks the care the patient receives. To ensure consistent care for all members, health plans establish guidelines for appropriate care for various situations. Most HMOs use nationally recognized guidelines — such as the American College of Obstetricians To ensure consistent care and Gynecologists (ACOG) guidelines for length -of -stay in a for all members, health hospital after giving birth. Many HMOs also establish their plans establish guidelines own specific guidelines. At PacifiCare, physicians and for appropriate care for medical management staff develop guidelines together, various situations. using national standards as a starting point. These guidelines, however, are just that — guides. Each physician makes indi- vidual medical decisions for his or her patients based on each patient's unique situation. Reliable Reimbursement Managed care also has reinvented physician income. Many HMOs compensate their physicians through a system called capitation, in which the health plan pays a physician (or physician group) a set fee each month for each member who selects a specific physician for his or her primary care physi- cian. Physicians provide medical services for their patients from these capitation funds, but physicians are protected from excessive financial risk — for patients with conditions involving extensive care — through stop -loss protections. The advantages of capitation are many. Capitation, or paying physicians a fixed amount per member per month, aligns financial and quality incentives. This system encourages doctors to provide effective preventive care. (Under fee -for - service medicine, doctors were paid after the fact for their services. They had little incentive to practice preventive care, because most fees were generated when people got sick.) To check that capitation is working as it should, quality health plans continuously review physician performance to guard against both underdelivery and overdelivery of health cam services to patients, to ensure that patients get appropriate care. Many physicians, too, enjoy the freedom that comes from not having to do more to make more. The physician -HMO rela- tionship continues to be reinvented, however. Much of the unease about HMOs is led by physicians, many of whom are concerned primarily about their compensation — although a recent American Medical Association study found that physi- cians are being compensated now at an average of $199,000 per year, an all-time high.11 To reach common ground, HMOs FhfLQwe ® are revising quality, compensation and risk -sharing processes. Originally, the HMO industry steered hard toward extremes of external utilization review of physician practices, to combat escalating costs and unaffordable premiums. At that time, some of the cost -reducing policies HMOs used in- volved onerous systems and sometimes created a barrier between patient and physician. As physician -plan communi- cations have improved, and as physicians and patients have become accustomed to HMOs, health plans have turned from restrictive policies toward health management pro- grams, quality measurement and risk sharing with providers to promote effective, appropriate care. The industry, how- ever, is yet to convince all consumers of its good intentions. As part of this "stepping back," PacifiCare this year is moving from contracting with a single large physician group in Denver to direct contracting with smaller physician management groups (PMGs). We believe sharing more decision -making responsibilities with established groups of primary rare and specialty physicians who care for patients will benefit physi- cians and members by strengthening the patient/physician relationship. As this process moves forward, we hope to share more functions with physician groups. To preserve a system of checks and balances among members, physicians and the plan, PacifiCare will retain responsibility for a number of critical functions, such as member services and member appeals. Tools for Better Care Freed from their "traffic cop" duties, HMOs can focus on supporting the doctor/patient relationship with tools includ- ing practice guidelines, peer comparisons, quality assess- ment, case management and, increasingly, insights about disease management and coordinated care. Freed from their "traffic cop" duties, HMOs can focus on Some of PacifiCare's programs in this area include the following: supporting the doctor/patient relationship witb tools Multifaceted health management programs allow us including practice guidelines, to work with doctors to treat patients with chronic peer comparisons, quality illnesses. We provide physicians with profiles of their assessment, case management patients with targeted chronic conditions. We contact and, increasingly, insights the patients to remind them to see their physicians, and about disease management encourage the doctors to do the same. And our health and coordinated care. management staff can help physicians and their office staff develop treatment plans for these members. • With our providers, we identify clinical "best prac- tices" and develop treatment guidelines that enable them to provide the most effective treatment to meet each patient's needs. • Physicians receive detailed reports on their practice patterns, including referral patterns, services pro- vided and costs incurred. This allows physicians to compare themselves to their peers and make adjust- �, � cJliC��� Rt a ments if necessary. 8 A wide range of regulatory measures exists to monitor HMOs, and most HMOs regularly scrutinize their own performance to ensure they are up to par. PhcffiCame • We regularly survey our members to learn how they feel about the quality of care and level of service they have received from PacifiCare's physicians and their staff. Then we share the results with doctors and physician groups so that, when necessary, they can make improvements in care and service. • PacifiCare empowers patients with programs such as the HEALTHWISE KnowledgebaseT", a free, online health information resource that gives members easy access to information that can support meaningful discussions with physicians and help members make informed health care decisions. HEALTH PLANS ARE ACCOUNTABLE TOTHE PUBLIC HMOs do not operate in a void, despite what Congressional scandal -mongering and outrageous media headlines would have us believe. A wide range of regulatory measures exists to monitor HMOs, and most HMOs regularly scrutinize their own performance to ensure they are up to par. As the health care industry evolves, anxiety about HMOs remains high, and many members of Congress hope to ride the issue of HMO regulation into easy re-election in Novem- ber. What is less obvious, in the uproar about managed care "horror stories," is that much of the proposed HMO legisla- tion would duplicate policies and coverage already available. In addition to reducing competition by eliminating market- place choice as an agent of industry reform, these regula- tions would increase costs. For instance, when legislators decree that all health plans must offer the same benefits, even the minimum benefit required by law can price some purchasers out of the health coverage market — particularly as numerous mandated benefits begin adding up. Many legislators are well-intentioned, and they believe they are following their constituents' wishes. The trouble is, not all citizens have the full picture. In a recent survey by the Kaiser Family Foundation and Harvard University, a majority of respondents (72 percent) supported the issues raised in Congress, in the abstract. But that support plummeted when pollsters asked if the respondents would still favor the pro- posals if they raised premium costs, increased government involvement or led employers to drop coverage. If premiums were raised by $1 to $5 as a result of legislation, only 43 percent would support those laws. That number fell further, to 28 percent, if premiums increased by $15 to $20 a month.12 9 National Patient Satisfaction with HMO and Fee -for -Service Care by Healtb Status and Age Good to Excellent Health Under 65 Poorto Fair Health Under 65 Good to Excellent Health Over 65 Poorto Fair Health Over 65 RM0111111111111 FFS 0 50 100 Percent somewhat, very or completely satisfied (Source: National Researcb Corporation, Healtbcare Market Guide t? survey, September 1996) PacifiCare Member Satisfaction Ratings Percent somewbat or very satisfied Commercial HMO Medicare -Risk HMO (Source: PacifiCare member surveys, May 20, 1999) PacffiGues Specific Regulation of Health Plaits • HMO licensure. While all health insurance carriers in this state are regulated by the Colorado Division of Insurance, managed care plans follow specific regula- tions that allow them to operate HMO plans. HMOs hold licensure from the federal government, and to maintain that licensure, plans must meet certain financial requirements and offer specific types of care. • Medicare HMO regulation. Some health plans offer Medicare -risk HMOs to individuals who are eligible for Medicare. These plans are directly accountable to the federal Health Care Financing Administration (HCFA). To continue to offer a Medicare HMO, plans must demonstrate that they meet specific HCFA require- ments. HCFA provides additional oversight by review- ing all materials Medicare HMO plans send to mem- bers to ensure they do not violate Medicare provisions or contain inaccuracies about plan benefits. • Nonprofit "watchdogs." An important oversight for HMO plans is provided by the National Committee for Quality Assurance (NCQA), a nonprofit watchdog organization that accredits HMOs if they meet a set of stringent quality and service requirements. NCQA auditors examine HMOs' coverage, customer service, quality improvement and monitoring systems, com- munications tools and management. Based on what the audit reveals, NCQA grants deserving HMOs one- year or three-year (full) accreditation. PacifiCare of Colorado holds Full Accreditation from the NCQA. As of Dec. 31, 1997, four of Colorado's 18 HMOs had achieved Full Accreditation.13 • Business groups. Large purchasers of health care have themselves joined together to influence how health care is delivered. This informal oversight is provided to HMOs via groups like the Colorado Business Group on Health, which helps HMOs understand what the health care marketplace wants from health plans. Another Colorado organization, The Alliance Cooperative for Health Insurance Purchasing, is a not -for -profit collective that allows small-business employers to pool their resources and leverage their influence on the Colorado health care market's price, service and accountability standards. • Member reporting mechanisms. To satisfy our most crucial audiences — members and employers that purchase our plans — HMOs can and will change in response to market demands and member feed- back As a result, HMOs have achieved high levels of member satisfaction. (See sidebar.) To learn what our members think of our service, PacifiCare con- ducts telephone and written surveys of our members on a regular basis. Then we take what we learn and use it to plot our course for future changes. 10 • Appeals and grievance processes. When an indi- vidual member is dissatisfied with the care he or she has received, health plans handle the issue in a variety of ways. All HMOs have established proce- dures for ensuring members have a way to make their voices heard. At PacifiCare, members are encouraged to speak first with their primary care physicians regarding any concerns about their medical care. If the situation is not resolved, the process moves through several levels to an impartial board which hears member appeals and makes a decision, binding on the plan, about each case. PacifiCare, in addition, employs a full-time member advocate to guide members through the appeals process, help them understand what they need to do to appeal a coverage deci- sion and ensure that they can exercise all of their options. THE VIEW FROM PACIFICARE Since 1974, PacifiCare and its predecessor companies have been in the vanguard of managed care in Colorado. rado no Colorado now PacifiCare of Colo PacifiCare of Colorado now covets more than 400,000 covers more than members statewide. Since 1985, the company also has been mem mem members statewide. Since a leader in Medicare managed care, and approximately 1-985, the company also has 55,000 Coloradans belong to Secure Horizons, PacifiCare's been a leader in Medicare Medicare HMO plan. managed care, and approxi- mately 55,000 Coloradans The "managed care industry" isn't as monolithic as that term belong to Secure Horizons, might sound. The industry, and every organization in it, is PacifiCare's Medicare constantly changing. PacifiCare is emblematic of that change HMO plan. _ we've undergone transformations from our name to our benefits to our organizational structure. Below, we'd like to outline some of the ways we work today. Creating a FrameworkThat Improves the Way Health Care Works PacifiCare provides a structure that organizes health care delivery in a different way from traditional fee -for -service medicine and helps our physicians and members be smart and effective partners with each other. We offer health care via a patient -centered health care system. To us, that means everything we do is designed to provide quality, affordable, easy -to -use health care. • PacifiCare works with physicians to ensure they understand how to guide their patients through their PacifiCare benefits, so that processes such as referrals work smoothly for patients and physicians. • In our customer service department, members are seldom kept waiting longer than 20 seconds, and je® representatives are trained to answer most questions 11 quickly and clearly. If representatives don't know an answer, they know where to get one. • We have invested in information technology to make member records both accessible to those who have a need — and a right — to them, and protected from those who don't. • Our member appeals process is outlined clearly in our member communications. To make sure mem- bers know what to expect, we employ a full-time principal member advocate who guides members through the appeals process. • We work to make using an HMO easy for our mem- bers. For specialty care, physicians can process referrals over the telephone, so confirmation is mailed to members within 48 hours — faster for urgent situations. PacifiCare contracts with hun- dreds of pharmacies in Colorado, making it easy for members to fill prescriptions in the neighborhood of their work or home. Improving the Health of Our Members Our efforts affect more than just our own members and providers. Because we are one of Colorado's largest health plans, our efforts to improve the health of our members influence the entire community's well-being. As part of our responsibility to the communities we serve, we are involved in numerous health and wellness programs for everyone from As part of our responsibility children to seniors: to the communities we serve, In partnership with Centura Health, a local hospital we are involved in numerous system, we offer "Set the Pace," a walking program for health and wellness programs Denver adults ages 55 and older. "Set the Pace" gives for everyone from cbildren older adults a framework for creating an exercise to seniors. regimen, helps them meet walking partners, and provides ongoing support and information about health, exercise and lifestyle issues from PacifiCare, Centura Health and community experts. • For three years, Secure Horizons, PacifiCare's Medi- care HMO, and the Alzheimer's Association have partnered to offer Memories in the Making, a cre- ative an expression program, offered in 32 locations around Colorado, for individuals with Alzheimer's disease. Last year, the Memories in the Making art auction generated $50,000 in research funds for the Alzheimer's Association, Rocky Mountain Chapter. • PacifiCare provides health care coverage for Denver Public Schools students through the Colorado Department of Public Health and Environment's School -Based Health Centers in Denver. • PacifiCare works with nonprofit organizations to expand their educational efforts. For example, with the American Heart Association, PacifiCare sponsors 12 PacifiCare believes that tbougbtful attention and dialogue about etbical issues is an essential part of a good health care system. PacffiGme an elementary school heart -health education pro- gram called "HeartPower!" With local chapters of the American Diabetes Associa- tion, PacifiCare helps to assess the quality of care diabetics receive in Colorado and to develop guide- lines for improving performance on critical proce- dures for this population. PacifiCare also has pro- vided financial support to the Pueblo Network for Education and Awareness About Diabetes and worked with them to develop a community diabetes awareness program. As part of its participation in the Colorado Guide- lines Collaborative, PacifiCare is taking the lead on developing guidelines for diabetes treatment that will be used by HMOs and physician practice groups throughout the state. Supporting Doctors So They Can Provide Better Care PacifiCare also is an innovator in strengthening physician relationships. In 1998, PacifiCare has begun moving toward a new way of contracting with physicians, based on physi- cians' needs and wants. The growing trend is toward physi- cians creating smaller, more flexible medical groups to con- tract with health plans. Physicians are increasingly asking for more autonomy and flexibility in their practices. To support physicians and meet their changing needs, PacifiCare this year will end its long-standing contractual arrangement with Columbine Medical Group, a large physician management organization through which PacifiCare has arranged all physician contracts in Denver, and will begin contracting directly with individual physician groups. The company already has contracted with smaller groups in other areas of Colorado. PacifiCare believes that thoughtful attention and dialogue about ethical issues is an essential part of a good health care system. To bring the important matter of ethics home, PacifiCare in 1996 established an ethics committee compris- ing PacifiCare staff, health care providers, members of the clergy, attorneys, ethicists and consumers. The committee meets bimonthly to gather information about and consider ethical issues related to managed care. The group's discus- sion culminates in recommendations that PacifiCare uses to improve health plan policies and practices and to educate employees. In addition, PacifiCare staff is involved with the broader issue of health care ethics in Colorado: Several members of PacifiCare's medical staff sit on community ethics committees, including the Pikes Peak Forum on Medical Ethics, the Penrose -St. 13 Francis Ethics Committee and the Colorado Collaboration on End -of -Life Care. • In 1996 PacifiCare worked with other Colorado H Os and medical groups to establish the Rocky Mountain Center for Healthcare Ethics to provide organizations, businesses, communities and individuals with re- sources to recognize and respond to the ethical dimensions of health care. The Center has drafted a code of ethics for managed care, which health plans serving members in this region voluntarily sign. In the changing health care marketplace in Colorado and nationally, HMOs have played — and will continue to play — a starring role. At PacifiCare, we believe education about HMOs is key to strengthening the improvements to health care access, quality and affordability that managed AtPacifiCare,the believe care has helped introduce. This paper was created to help education about out HMOs dispel some widely held myths about HMOs, and to provide is key to strengtberting the a well-rounded view of why HMOs operate as they do. Only improvements to health care when consumers, purchasers, physicians and legislators fully access, quality and understand HMOs will this very popular style of health plan affordability that managed reach its full potential for improving the U.S. health care care bas belped introduce. marketplace. For more information about PacifiCare and HMOs, please contact Laura Wegscheid, PacifiCare director of communica- tions, at 1-800-877-6685. Millenson, Michael L., "The New American Health System: A Report to the American Association of Health Plans," Oct. 8, 1997, William M. Mercer, Incorporated, p. 7. = The Lewin Group, 1997 study. American Association of Health Plans. American Association of Health Plans, "Managed Care Facts," January 1998, p. 1. ' KPMG Peat Marwick 1997 survey. ° R. Miller, H. Luft, Health Affairs, Sept./Oct. 1997; R. Miller, H. Luft, Journal of the American Medical Association, May 1994. NCQA, "Me State of Managed Care Quality," 1997. ° L. Nelson et al., Mathematica Policy Research, Access to Care in Managed Care, PPRC, Nov 1996; also Health Affairs, March/April 1997. 9 Riley et al., The American journal of Public Health, Oct. 1994. 10 The Wall Street Journal, "Big Companies Fight Health Plan Rates," May 19, 1998. American Medical Association, April 1998. 'Z Kaiser Family Foundation/Harvard University survey, Jan. 1998. P_ _ adfi a " NCQA, "Managed Care Organization Accreditation Status List," Dec. 31, 1997. 14 No Text No Text Chris arrived at PacifiCare in May, 1996 where she actually "returned to her roots" since Lincoln National, her rust employer, after many name changes, is now PacifiCare. She serves as an Account Manager wherein she handles her group business (renewals), conducts membership meetings with her existing block of clients, and services all needs of her group plan administrators. During this period, Chris also completed her Bachelor of Science in Marketing at the University of Colorado at Denver attending evening courses while maintaining employment in the health care industry. B. Physician Specific Issues 1. Please outline the physician selection criteria utilized by your managed care program in contracting with primary care and specialty physicians. How are their credentials verified? How often are they reviewed? Physicians are recredentaaled biennially. Principal features of the credentialing and recredentialing process include the following: ♦ graduation from an accredited college of medicine ♦ valid state licensure (state of practice) ♦ board certification/eligibility appropriate to practice area ♦ DEA registration and unrestricted prescribing privileges ♦ active admitting privileges at a network hospital ♦ malpractice coverage within a minimum of $1,000,000/$3,000,000 ♦ detailed malpractice history ♦ detailed history of disciplinary action or litigation ♦ sanctions through National Practitioner Data Bank ♦ history of sanctions through NPDB ♦ history of conviction for fraud or felony ♦ medical records ♦ general health status ♦ NH/CD status Credentials are verified through sources such as: The National Practitioner Data Bank, The State Board of Medical Examiners, The American Board of Medical Specialties and particular hospitals. 2. How is the quality of care and physician cost efficiency monitored on an ongoing basis? How often is this review conducted? The overall effects of the programs are evaluated annually and presented to the Utilization Review (UR) and Quality Improvement Clinical Sub Committees. This annual evaluation includes programs, policies, procedures and criteria. Member/provider survey information related to UR issues is also evaluated and may result in changes if appropriate. Aspects that are monitored include: PT health status indicators outcomes; medical necessity, diagnosis management, clinical indicators; setting appropriateness; and efficacy of care. M City of Fort Collins Managed Care Accessibility Analysis July 27, 1998 A report on the accessibility of the PacifiCare Colorado Primary Care Physicians for the employees of City of Fort Collins PacifiCare Colorado Primary Care Physicians - City of Fort Collins Table of Contents i Providerlocations 1............................................................................................................. PacifiCare Colorado Primary Care Physicians Colorado Colorado Service Area Employeelocations..................................................................................................................... 2 City of Fort Collins PacifiCare Colorado Primary Care Physicians Colorado 2 PCPs within 10 Miles All Colorado Service Area Accessibilitysummary ................................................................................................................. City of Fort Collins 3 PacifiCare Colorado Primary Care Physicians 2 PCPs within 10 Miles With Accessibilitysummary ................................................................................................................. 4 City of Fort Collins PacifiCare Colorado Primary Care Physicians 2 PCPs within 10 Miles Without Zipcode detail information.......................................................................................................... City of Fort Collins 5 PacifiCare Colorado Primary Care Physicians 2 PCPs within 10 Miles All Access standard comparison...................................................................................... City of Fort Collins 6 PacifiCare Colorado Primary Care Physicians PacifiCare Colorado Primary Care Physicians - City of Fort Collins t Provider locations a service area: Colorado Service Area x Multiple provider locations (2) PacifiCare Colorado Primary Care Physicians - City of Fort Collins Employee locations iaiv �cy��„N. raan�.are �.owraao rnmary care Employee without access (13) Access standard: 2 PCPs within 10 Miles ❑ Service area: Colorado Service Area PacifiCare Colorado Primary Care Physicians - City of Fort Collins 3 Accessibility summary Accessibility analysis specifications Provider group: PacifiCare Colorado Primary Care Physicians 1,300 providers at 1,294 locations (based on 1,300 records) Employee group: City of Fort Collins 1,207 employees Access standard: 2 PCPs within 10 Miles Employees with desired access: 1,194 (98.9%) Average distance to a choice of providers for employees with desired access Number of providers 1 2 3 4 5 Miles 0.8 1.3 L1.7 1.9 2.1 Key geographic areas Employees with desired access Total Number Percent Average distance to 2 providers County number of employees LARIMER 1,144 1,133 99 1.3 WELD 49 48 98 2.1 BOULDER 7 7 100 2.4 ADAMS 2 2 100 0.6 JEFFERSON 2 2 100 0.9 ARAPAHOE 1 1 100 0.5 DENVER 1 1 100 0.2 4 PacifiCare Colorado Primary Care Physicians - City of Fort Collins 4 Accessibility summary Accessibility analysis specifications Provider group: PacifiCare Colorado Primary Care Physicians 1,300 providers at 1,294 locations (based on 1,300 records) Employee group: City of Fort Collins 1,207 employees Access standard: 2 PCPs within 10 Miles Employees without 13 (1.1%) desired access: Average distance to a choice of providers for employees without desired access Number of providers 1 2 3 4 5 Miles 29.7 32.0 32.7 33.7 33.9 Key geographic areas Employees without desired access Total Number Percent Average distance to 2 providers County number of employees LARIMER 1,144 11 1 27.6 WELD 49 1 2 10.2 DELTA 1 1 100 102.1 PacifiCare Colorado Primary Care Physicians - City of Fort Collins Zip code detail information 5.1 City of Fort Collins All employees Total Total Average distance County/City Zip code number of employees number of providers Pct w wo to providers 1 2 ADAMS BROOMFIELD 80020 1 19 100 0 0.2 0.8 80234 1 10 100 0 0.4 0.4 Subtotal BROOMFIELD 2 29 100 0 0.3 0.6 Subtotal ADAMS 2 29 100 0 0.3 0.6 ARAPAHOE AURORA 80014 1 28 100 0 0.4 0.5 Subtotal AURORA 1 28 100 0 0.4 0.5 Subtotal ARAPAHOE 1 28 100 0 0.4 0.5 BOULDER BOULDER 80302 1 2 100 0 0.8 1.0 80304 2 34 100 0 0.0 0.3 Subtotal BOULDER 3 36 100 0 0.3 0.5 LAFAYETTE 80026 1 8 100 0 2.5 2.8 Subtotal LAFAYETTE 1 8 100 0 2.5 2.8 LONGMONT 80501 2 29 100 0 2.9 3.5 Subtotal LONGMONT 2 29 100 0 2.9 3.5 LYONS 80540 1 1 100 0 4.9 5.3 Subtotal LYONS 1 1 100 0 4.9 5.3 Subtotal BOULDER 7 74 100 0 2.0 2.4 DELTA DELTA 81416 1 0 0 100 100.7 102.1 Subtotal DELTA 1 0 0 100 100.7 102.1 Subtotal DELTA 1 0 0 100 100.7 102.1 DENVER DENVER 80252 1 0 100 0 0.2 0.2 Subtotal DENVER 1 0 100 0 0.2 0.2 Access stanaara: 2 vuvs within 10 Miles Provider group: PacifiCare Colorado Primary Care Physicians PacifiCare Colorado Primary Care Physicians - City of Fort Collins Zip code detail information 5.2 City of Fort Collins All employees Total Total Average distance County/City Zip code number of employees number of providers Pct w 100 wo 0 to providers 1 0.2 2 0.2 Subtotal DENVER 1 0 JEFFERSON ARVADA 80003 1 4 100 0 0.7 1.0 Subtotal ARVADA 1 4 100 0 0.7 1.0 DENVER 80215 1 15 100 0 0.4 0.7 Subtotal DENVER 1 15 100 0 0.4 0.7 Subtotal JEFFERSON 2 19 100 0 0.6 0.9 LARIMER BELLVUE 80512 16 0 100 0 4.2 4.5 Subtotal BELLVUE 16 0 100 0 4.2 4.5 BERTHOUD 80513 1 3 100 0 2.5 3.9 Subtotal BERTHOUD 1 3 100 0 2.5 3.9 DRAKE 80515 1 0 100 0 3.7 4.0 Subtotal DRAKE 1 0 100 0 3.7 4.0 ESTES PARK 80517 2 6 100 0 0.5 0.7 Subtotal ESTES PARK 2 6 100 0 0.5 0.7 FORT COLLINS 80521 195 0 100 0 1.0 1.4 80522 11 0 100 0 1.4 1.5 80524 184 47 100 0 0.2 0.7 80525 248 12 100 0 0.8 1.3 80526 314 15 100 0 0.6 1.1 80527 7 0 100 0 0.7 2.2 Subtotal FORT COLLINS 959 74 100 0 0.7 1.1 LAPORTE 80535 44 0 100 0 1.7 2.0 Subtotal LAPORTE 44 0 100 0 1.7 2.0 LIVERMORE 80536 8 0 0 100 24.6 27.4 80545 3 0 0 100 27.1 28.2 Subtotal LIVERMORE 11 0 0 100 25.2 27.6 Access stan0ara: Z YGYs wltnln 1 a Mlles Provider group: PacifiCare Colorado Primary Care Physicians PacifiCare Colorado Primary Care Physicians - City of Fort Collins Zip code detail information City of Fort Collins 5.3 All employees Total Total Average distance County/City Zip code number of employees number of providers pct w wo to providers 1 2 LARIMER LOVELAND 80537 32 11 100 0 0.8 1.5 80538 42 17 100 0 0.9 12 80539 2 0 100 0 0.6 1.2 Subtotal LOVELAND 76 28 100 0 0.9 1.3 MASONVILLE 80541 2 0 100 0 0.6 1.2 Subtotal MASONVILLE 2 0 100 0 0.6 1.2 TIMNATH 80547 3 0 100 0 0.9 2.1 Subtotal TIMNATH 3 0 100 0 0.9 2.1 WELLINGTON 80549 29 0 100 0 3.0 3.7 Subtotal WELLINGTON 29 0 100 0 3.0 3.7 Subtotal LARIMER 1,144 111 99 1 1.1 1.6 WELD AULT 80610 2 1 100 0 1.1 4.9 Subtotal AULT 2 1 100 0 1.1 4.9 EATON 80615 5 1 100 0 0.8 3.1 Subtotal EATON 5 1 100 0 0.8 3.1 EVANS 80620 2 0 100 0 1.1 1.5 Subtotal EVANS 2 0 100 0 1.1 1.5 GREELEY 80631 4 50 100 0 0.0 0.6 80634 4 1 100 0 2.0 2.2 Subtotal GREELEY 8 51 100 0 1.0 1.4 JOHNSTOWN 80534 1 1 100 0 0.7 5.7 Subtotal JOHNSTOWN 1 1 100 0 0.7 5.7 PIERCE 80650 2 0 100 0 3.6 8.9 Subtotal PIERCE 2 0 100 0 3.6 8.9 PLATTEVILLE 80651 1 0 0 100 7.8 10.2 Subtotal PLATTEVILLE 1 0 1 0 1100 1 7.8 1 10.2 Access stanaara: L vuvs witnln 1 u wes Provider group: PacifiCare Colorado Primary Care Physicians PacifiCare Colorado Primary Care Physicians - City of Fort Collins Zip code detail information 5.4 City of Fort Collins County/City Zip code Total number of employees Total number of providers All employees pct w wo 100 0 100 0 98 2 Average distance to providers 1 0.6 0.6 1.0 2 1.3 1.3 2.2 WELD WINDSOR Subtotal WINDSOR Subtotal WELD 80550 28 28 49 6 6 60 TOTALS 1,207 321 99 1 1.1 1.7 Access standard: 2 PCPs within 10 Miles Provider group: PacifiCare Colorado Primary Care Physicians PacifiCare primary care physicians' performance measurement is based on a number of factors. The total health care cost for members assigned to each primary care physician is compared to the total health care cost of all PacifiCare physicians within their peer group. On a quarterly basis, primary care physicians receive reporting on economical markers based upon the performance of the individual physician as well as the aggregate performance of all of the physicians. In addition, performance is measured based upon member satisfaction, office site reviews, access time for appointments, chart reviews, member turnover rate and ability to accept additional PacifiCare members. PacifiCare also monitors performance based upon hospital days per thousand, lengths of stay, unnecessary hospital days and other factors such as pediatric immunization rates, mammography rates, cholesterol screening and cesarean section rates. 3. How many physician members have been terminated within the last two years? For what reasons? What provisions are made for patients of terminated physicians? What has the average turnover rate been of the physician network over the past two years? Physician turnover rate for 1996 was 2.6%. Physician turnover rate for 1997 was 5.95%, of which one physician left the health plan involuntarily. Primary reasons for MD turnover would include: ♦ retirement ♦ practice relocation ♦ change in practice status. PacifiCare of Colorado requires a 90-day termination notice from physicians. PacifiCare will work with all clients to coordinate the most appropriate methodology for notification to clients' members, including mailing to affected individuals and instructions on any action needed in response to the change. 4. How many primary care physicians do you directly contract with in the Plan's service area? How many specialists? Please enclose a copy of your directory, including any mental health/substance abuse providers. PacifiCare currently contracts with 1265 primary care physicians and 2531 specialists statewide. This represents 50.2% and 50.4% respectively of the available physicians in the area. Please see Provider Directory attachment for a list of contracted physicians. 5. Are there any specific areas of organization's contracted physicians? patients requiring these services? care which would not be available from your If so, which ones? What provisions are made for All covered services are made available to members. If required care is not available in Fort Collins, PacifiCare will make care available through the Denver network. If services are limited in the Denver area, PaciflCare will make care available as required. 7 PacifiCare Colorado Primary Care Physicians - City of Fort Collins 6 Access standard comparison Access standard comparison City of Fort Collins PacifiCare Colorado Primary Care Physicians 100% P e 80 r c e n It 60 0 f e m 40 P I 0 Y e e 20 s 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Miles to a choice of providers 1 provider 2 providers 3 providers 4 providers 5 providers Average distance to a choice of PacifiCare Colorado Primary Care Physicians Number of providers 1 2 3 4 5 Miles 1.1 1.7 2.0 2.3 2.5 City of Fort Collins Managed Care Accessibility Analysis July 27, 1998 A report on the accessibility of the PacifiCare Colorado OB/GYNs for the employees of City of Fort Collins f PacifiCare Colorado OB/GYNs - City of Fort Collins Table of Contents Providerlocations....................................................................................................................... 1 PacifiCare Colorado OB/GYNs Colorado Colorado Service Area Employeelocations..................................................................................................................... 2 City of Fort Collins PacifiCare Colorado OB/GYNs Colorado 2 Providers within 10 Miles All Colorado Service Area Accessibilitysummary ................................................................................................................. 3 City of Fort Collins PacifiCare Colorado OB/GYNs 2 Providers within 10 Miles With Accessibilitysummary ................................................................................................................. 4 City of Fort Collins PacifiCare Colorado OB/GYNs 2 Providers within 10 Miles Without Zipcode detail information.......................................................................................................... 5 City of Fort Collins PacifiCare Colorado OB/GYNs 2 Providers within 10 Miles All Access standard comparison...................................................................................................... 6 City of Fort Collins PacifiCare Colorado OB/GYNs PacifiCare Colorado OB/GYNs - City of Fort Collins Provider locations • Provider locations ❑ Service area: Colorado Service Area PacifiCare Colorado OB/GYNs - City of Fort Collins Employee locations • Employee with access (1,156) Provider group: PacifiCare Colorado OB/GYNs (245) o Employee without access (51) Access standard: 2 Providers within 10 Miles ❑ Service area: Colorado Service Area PacifiCare Colorado OB/GYNs - City of Fort Collins Accessibility summary Accessibility analysis specifications Provider group: PacifiCare Colorado OB/GYNs 245 providers at 245 locations (based on 245 records) Employee group: city of Fort Collins 1,207 employees Access standard: 2 Providers within 10 Miles Employees with desired access: 1,156 (95.8%) Average distance to a choice of providers for employees with desired access Number of providers 1 2 3 4 5 Miles 2.7 3.7 4.0 4.2 4.5 Key geographic areas Employees with desired access Total Average distance number of County employees Number Percent to 2 providers LARIMER 1,144 1,099 96 3.6 WELD 49 44 90 5.9 BOULDER 7 7 100 4.0 ADAMS 2 2 100 2.3 JEFFERSON 2 2 100 2.1 ARAPAHOE 1 1 100 2.4 DENVER 1 1 100 1.0 PacifiCare Colorado OB/GYNs - City of Fort Collins 4 Accessibility summary Accessibility analysis specifications Provider group: PacifiCare Colorado os/GYNs 245 providers at 245 locations (based on 245 records) Employee group: city of Fort Collins 1,207 employees Access standard: 2 Providers within 10 Miles Employees without desired access: 51 (4.2%) Average distance to a choice of providers for employees without desired access Number of providers 2 3 4 5 Miles 14.8 19.1 19.6 19.9 20.2 Key geographic areas Employees without desired access Total Average distance number of County employees Number Percent to 2 providers LARIMER 1,144 45 4 17.0 WELD 49 5 10 12.1 DELTA 1 1 100 153.2 PacifiCare Colorado OB/GYNs - City of Fort Collins Zip code detail information 5.1 City of Fort Collins All employees Total Total Average distance Zip number of number of Pct to providers 1 2 County/City code employees providers w wo ADAMS BROOMFIELD 80020 1 1 100 0 2.3 2.5 80234 1 0 100 0 1.6 2.1 Subtotal BROOMFIELD 2 1 100 0 2.0 2.3 Subtotal ADAMS 2 1 100 0 2.0 2.3 ARAPAHOE AURORA 80014 1 1 100 0 1.9 2.4 Subtotal AURORA 1 1 100 0 1.9 2.4 Subtotal ARAPAHOE 1 1 100 0 1.9 2.4 BOULDER BOULDER 80302 1 0 100 0 2.0 4.4 80304 2 7 100 0 0.7 0.9 Subtotal BOULDER 3 7 100 0 1.1 2.0 LAFAYETTE 80026 1 0 100 0 4.9 5.0 Subtotal LAFAYETTE 1 0 100 0 4.9 5.0 LONGMONT 80501 2 4 100 0 3.2 5.2 Subtotal LONGMONT 2 4 100 0 3.2 5.2 LYONS 80540 1 0 100 0 5.5 6.4 Subtotal LYONS 1 0 100 0 5.5 6.4 Subtotal BOULDER 7 11 100 0 2.9 4.0 DELTA DELTA 81416 1 0 0 100 121.3 153.2 Subtotal DELTA 1 0 0 100 121.3 153.2 Subtotal DELTA 1 0 0 100 121.3 153.2 DENVER DENVER 80252 1 0 100 0 0.4 1.0 Subtotal DENVER 1 0 100 0 0.4 1.0 Access standard: 2 Providers within 10 Miles Provider group: PacifiCare Colorado OB/GYNs PacifiCare Colorado OB/GYNs - City of Fort Collins Zip code detail information 5.2 City of Fort Collins All employees Total Total Average distance Zip number of number of Pct to providers 1 2 County/City code employees providers w wo Subtotal DENVER 1 0 100 0 0.4 1.0 JEFFERSON ARVADA 80003 1 0 100 0 2.1 2.5 Subtotal ARVADA 1 0 100 0 2.1 2.5 DENVER 80215 1 0 100 0 1.2 1.7 Subtotal DENVER 1 0 100 0 1.2 1.7 Subtotal JEFFERSON 2 0 100 0 1.7 2.1 LARIMER BELLVUE 80512 16 0 75 25 8.3 9.3 Subtotal BELLVUE 16 0 75 25 8.3 9.3 BERTHOUD 80513 1 0 100 0 6.7 7.2 Subtotal BERTHOUD 1 0 100 0 6.7 7.2 DRAKE 80515 1 0 100 0 6.4 6.7 Subtotal DRAKE 1 0 100 0 6.4 6.7 ESTES PARK 80517 2 1 0 100 1.3 20.1 Subtotal ESTES PARK 2 1 0 100 1.3 20.1 FORT COLLINS 80521 195 0 100 0 3.3 4.2 80522 11 0 100 0 3.7 4.7 80524 184 1 92 8 2.5 5.1 80525 248 11 100 0 1.0 1.6 80526 314 0 100 0 3.0 3.3 80527 7 0 100 0 1.3 2.2 Subtotal FORT COLLINS 959 12 98 2 2.5 3.4 LAPORTE 80535 44 0 91 9 5.2 8.1 Subtotal LAPORTE 44 0 91 9 5.2 8.1 LIVERMORE 80536 8 0 0 100 31.4 33.8 80545 3 0 0 100 29.7 34.0 Subtotal LIVERMORE 11 0 0 100 30.9 33.9 Access standard: 2 Providers within 10 Miles Provider group: PacifiCare Colorado OB/GYNs PacifiCare Colorado OB/GYNs - City of Fort Collins 5.3 Zip code detail information City of Fort Collins All employees Total Total Average distance Zip number of number of pct to providers 1 2 County/City code employees providers w wo LARIMER LOVELAND 80537 32 0 100 0 3.0 3.8 80538 42 6 100 0 1.5 2.5 80539 2 0 100 0 3.2 3.8 Subtotal LOVELAND 76 6 100 0 2.2 3.1 MASONVILLE 80541 2 0 100 0 3.2 3.8 Subtotal MASONVILLE 2 0 100 0 3.2 3.8 TIMNATH 80547 3 0 100 0 1.5 2.3 Subtotal TIMNATH 3 0 100 0 1.5 2.3 WELLINGTON 80549 29 0 69 31 6.4 9.7 Subtotal WELLINGTON 29 0 69 31 6.4 9.7 Subtotal LARIMER 1,144 19 96 4 3.0 4.1 WELD AULT 80610 2 0 50 50 9.3 10.1 Subtotal AULT 2 0 50 50 9.3 10.1 EATON 80615 5 0 100 0 5.1 5.9 Subtotal EATON 5 0 100 0 5.1 5.9 EVANS 80620 2 0 100 0 2.3 2.6 Subtotal EVANS 2 0 100 0 2.3 2.6 GREELEY 80631 4 8 100 0 1.3 1.8 80634 4 0 100 0 3.1 3.6 Subtotal GREELEY 8 8 100 0 2.2 2.7 JOHNSTOWN 80534 1 0 0 100 9.3 10.6 Subtotal JOHNSTOWN 1 0 0 100 9.3 10.6 PIERCE 80650 2 0 0 100 13.1 13.3 Subtotal PIERCE 2 0 0 100 13.1 13.3 PLATTEVILLE 80651 1 0 0 100 12.6 12.6 Subtotal PLATTEVILLE 1 1 1 0 1 0 1100 1 12.6 1 12.6 Access standard: 2 Providers within 10 Miles Provider group: PacifiCare Colorado OB/GYNs 6. Do physicians pay a membership fee to the managed care provider? If so, how much is the fee and how often is it charged? PacifiCare does not have a membership fee for physicians. 7. Does your physician contract require they utilize a network lab for all or certain lab procedures? If so, please detail this requirement and the specifics of the lab contract. PacifiCare of Colorado contracts directly for the services of laboratory and radiology. Physicians are required to use the services of the contracted providers, except in geographically underserved areas. In rural areas, physicians are allowed to use services available to them, and services are then reimbursed on a fee -for -service basis. 8. Please provide a copy of your physician contract and physician office manual. Proprietary information 9. What ratio of physicians to participants do you maintain? What is the ratio currently in Larimer County? Current ratio for the Northern Region (Larimer & Weld counties) is 1:245. Specific region information can be computed from the GEO Access reports. 10. Please describe the professional liability insurance arrangement your organization maintains with respect to participating physicians. _Professional Liability Insurance (Malpractice) Information: Limit: $50,000,000 per occurrence Deductible: $50,000 Coverage is provided through Farmer's Insurance Company. Reinsurance (Stop -loss) information: $2,000,000 per individual, per lifetime $3009000 deductible Coverage provided by Allianz Life Insurance Company of North America 11. Provide a GeoAccess and disruption analysis/network analysis as described in the General Information section. Please see GEO Access attachment and Disruption Analysis attachments. 8 PacifiCare Colorado OB/GYNs - City of Fort Collins 5.4 Zip code detail information City of Fort Collins County/City Zip code Total number of employees Total number of providers All employees Pct w wo Average distance to providers 1 2 WELD WINDSOR Subtotal WINDSOR Subtotal WELD 80550 28 28 49 0 0 8 100 100 90 0 0 10 6.6 6.6 6.1 6.9 6.9 6.5 TOTALS 1,207 40 96 4 3.2 4.3 Access standard: 2 Providers within 10 Miles Provider group: PacifiCare Colorado OB/GYNs PacifiCare Colorado OB/GYNs - City of Fort Collins 6 Access standard comparison Access standard comparison City of Fort Collins PacifiCare Colorado OB/GYNs 100% P e 80 r c e n t 60 0 f e m 40 p 0 Y e e 20 s 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Miles to a choice of providers 1 provider 2 providers 3 providers 4 providers 5 providers Average distance to a choice of PacifiCare Colorado OB/GYNs Number of providers 1 2 3 4 5 Miles 3.2 4.3 4.6 4.9 5.2 City of Fort Collins Managed July 27, 1998 Care Accessibility Analysis A report on the accessibility of the PacifiCare Colorado Hospitals for the employees of City of Fort Collins PacifiCare Colorado Hospitals - City of Fort Collins Table of Contents Providerlocations....................................................................................................................... 1 PacifiCare Colorado Hospitals Colorado Colorado Service Area Employeelocations..................................................................................................................... 2 City of Fort Collins PacifiCare Colorado Hospitals Colorado 1 Provider within 20 Miles All Colorado Service Area Accessibilitysummary ................................................................................................................. 3 City of Fort Collins PacifiCare Colorado Hospitals 1 Provider within 20 Miles With Accessibilitysummary ................................................................................................................. 4 City of Fort Collins PacifiCare Colorado Hospitals 1 Provider within 20 Miles Without Zip code detail information.......................................................................................................... 5 City of Fort Collins PacifiCare Colorado Hospitals 1 Provider within 20 Miles All Accessstandard comparison...................................................................................................... 6 City of Fort Collins PacifiCare Colorado Hospitals PacifiCare Colorado Hospitals - City of Fort Collins Provider locations • Provider locations ❑ Service area: Colorado Service Area PacifiCare Colorado Hospitals - City of Fort Collins Employee locations • Employee with access (1,195) Provider group: PacifiCare Colorado Hospitals (43) a Employee without access (12) Access standard: 1 Provider within 20 Miles ❑ Service area: Colorado Service Area PacifiCare Colorado Hospitals - City of Fort Collins 3 Accessibility summary Accessibility analysis specifications Provider group: PacifiCare Colorado Hospitals 43 providers at 43 locations (based on 43 records) Employee group: city of Fort Collins 1,207 employees Access standard: 1 Provider within 20 Miles Employees with desired access: 1,195 (99.0%) Average distance to a choice of providers for employees with desired access Number of providers 2 3 4 5 Miles 4.7 10.1 20.7 24.9 27.7 Key geographic areas Employees with desired access Total Average distance number of County employees Number Percent to 1 provider LARIMER 1,144 1,133 99 4.6 WELD 49 49 100 8.3 BOULDER 7 7 100 5.2 ADAMS 2 2 100 5.7 JEFFERSON 2 2 100 2.8 ARAPAHOE 1 1 100 5.2 DENVER 1 1 100 1.2 PacifiCare Colorado Hospitals - City of Fort Collins 4 Accessibility summary Accessibility analysis specifications Provider group: PacifiCare Colorado Hospitals 43 providers at 43 locations (based on 43 records) Employee group: city of Fort Collins 1,207 employees Access standard: 1 Provider within 20 Miles Employees without desired access: 12 (1.0%) Average distance to a choice of providers for employees without desired access Number of providers 1 2 3 4 5 Miles 37.4 41.2 46.5 60.8 64.2 Key geographic areas County Total number of employees Employees without desired access Number Percent Average distance to 1 provider LARIMER DELTA 1,144 1 11 1 1 100 31.6 101.3 PacifiCare Colorado Hospitals - City of Fort Collins Zip code detail information 5.1 City of Fort Collins All employees Average distance Total Total Zip number of number of pct to a choice of County/City code employees providers w wo 1 provider ADAMS BROOMFIELD 80020 1 0 100 0 5.2 80234 1 0 100 0 6.2 Subtotal BROOMFIELD 2 0 100 0 5.7 Subtotal ADAMS 2 0 100 0 5.7 ARAPAHOE AURORA 80014 1 0 100 0 5.2 Subtotal AURORA 1 0 100 0 5.2 Subtotal ARAPAHOE 1 0 100 0 5.2 BOULDER BOULDER 80302 1 0 100 0 5.6 80304 2 0 100 0 3.7 Subtotal BOULDER 3 0 100 0 4.3 LAFAYETTE 80026 1 0 100 0 5.0 Subtotal LAFAYETTE 1 0 100 0 5.0 LONGMONT 80501 2 1 100 0 5.3 Subtotal LONGMONT 2 1 100 0 5.3 LYONS 80540 1 0 100 0 8.2 Subtotal LYONS 1 0 100 0 8.2 Subtotal BOULDER 7 1 100 0 5.2 DELTA DELTA 81416 1 0 0 100 101.3 Subtotal DELTA 1 0 0 100 101.3 Subtotal DELTA 1 0 0 100 101.3 DENVER DENVER 80252 1 0 100 0 1.2 Subtotal DENVER 1 0 100 0 1.2 Access standard: 1 Provider within 20 Miles Provider group: PacifiCare Colorado Hospitals PacifiCare Colorado Hospitals - City of Fort Collins Zip code detail information 5.2 City of Fort Collins All employees Average distance Total Total Zip number of number of Pct to a choice of County/City code employees providers w wo 1 provider Subtotal DENVER 1 0 100 0 1.2 JEFFERSON ARVADA 80003 1 0 100 0 2.5 Subtotal ARVADA 1 0 100 0 2.5 DENVER 80215 1 0 100 0 3.0 Subtotal DENVER 1 0 100 0 3.0 Subtotal JEFFERSON 2 0 100 0 2.8 LARIMER BELLVUE B0512 16 0 100 0 9.5 Subtotal BELLVUE 16 0 100 0 9.5 BERTHOUD 80513 1 0 100 0 8.9 Subtotal BERTHOUD 1 0 100 0 8.9 DRAKE 80515 1 0 100 0 7.8 Subtotal DRAKE 1 0 100 0 7.8 ESTES PARK 80517 2 1 100 0 0.9 Subtotal ESTES PARK 2 1 100 0 0.9 FORT COLLINS 80521 195 0 100 0 3.8 80522 11 0 100 0 4.3 80524 184 1 100 0 2.8 80525 248 0 100 0 4.5 80526 314 0 100 0 5.6 80527 7 0 100 0 6.3 Subtotal FORT COLLINS 959 1 100 0 4.4 LAPORTE 80535 44 0 100 0 6.1 Subtotal LAPORTE 44 0 100 0 6.1 LIVERMORE 80536 8 0 0 100 32.4 80545 3 0 0 100 29.4 Subtotal LIVERMORE 11 0 0 100 31.6 ACCeSS Stanaara: 1 Provider within 20 Miles Provider group: PacifiCare Colorado Hospitals C. Hospital/Facility Specific Issues What criteria are used to select hospitals and other health care facilities? How are the hospitals monitored for cost efficiency and quality of care on an ongoing basis? How often is this review conducted? Have any hospitals been terminated or dropped from the managed care program? Please describe circumstances. PacifiCare usually seeks out full -service hospitals. Hospitals are reviewed for state licensure, JCAHO accreditation, malpractice history and current malpractice coverage. If the facility is not JCAHO accredited, PacifiCare reviews their QA/QI program and conducts a site visit prior to contracting. It is essential that both physicians and hospitals meet the needs of PacifiCare as a network. Once credentialed and contracted, recredentialing takes place biennially. PacifiCare has not terminated a contract with a hospital within the past two years. PacifiCare has a Hospital Quality Subcommittee (HQS) that reviews hospital quality reporting. This assists the plan in determining the quality status of hospitals to determine areas for community initiatives or program development, and sharing of information, including best practices. QI/UM hospital representatives from participating hospitals are members of the committee. The committee reviews six key indicators plus satisfaction scores. PacifiCare has a Nursing Peer Review that reviews potential quality of care concerns involving nursing and ancillary care in a facility or ambulatory service. The committee conducts individual case review, obtains action plans as indicated, tracks and trends data and reports activities to the Physician Peer Review Committee. This data is used in the recredentialing process. Appropriateness of care/patient outcomes are monitored continuously. Our onsite review nurses apply a generic screen of quality indicators to all members seen in the inpatient setting and report individual case variances to our peer review process. Direct referrals from members, providers, and outside review agencies are also reviewed and problem solved through our peer review process. Feedback is provided to providers on each individual case reviewed. Patient outcomes are also tracked via our participation in HEDIS. Data is communicated to physicians on an annual basis via physician newsletters. Member and patient satisfaction surveys are conducted annually.. Feedback is provided to physicians via newsletters and on an individual basis as appropriate. 2. Identify all hospital/health care facilities that have contractual relationships with the managed care program. Please refer to pages 52-53 of Provider Directory attachment for a list of these providers. W PacifiCare Colorado Hospitals - City of Fort Collins 5.3 Zip code detail information City of Fort Collins Total Total All employees Average distance Zip number of number of Pct to a choice of County/City code employees providers w wo 1 provider LARIMER LOVELAND 80537 32 0 100 0 5.1 80538 42 1 100 0 3.2 80539 2 0 100 0 5.3 Subtotal LOVELAND 76 1 100 0 4.0 MASONVILLE 80541 2 0 100 0 5.3 Subtotal MASONVILLE 2 0 100 0 5.3 TIMNATH 80547 3 0 100 0 6.0 Subtotal TIMNATH 3 0 100 0 6.0 WELLINGTON 80549 29 0 100 0 6.8 Subtotal WELLINGTON 29 0 100 0 6.8 Subtotal LARIMER 1,144 3 99 1 4.8 WELD AULT 80610 2 0 100 0 10.1 Subtotal AULT 2 0 100 0 10.1 EATON 80615 5 0 100 0 6.1 Subtotal EATON 5 0 100 0 6.1 EVANS 80620 2 0 100 0 5.0 Subtotal EVANS 2 0 100 0 5.0 GREELEY 80631 4 1 100 0 4.5 80634 4 0 100 0 3.8 Subtotal GREELEY 8 1 100 0 4.2 JOHNSTOWN 80534 1 0 100 0 11.8 Subtotal JOHNSTOWN 1 0 100 0 11.8 PIERCE 80650 2 0 100 0 14.1 Subtotal PIERCE 2 0 100 0 14.1 PLATTEVILLE 80651 1 0 100 0 17.1 Subtotal PLATTEVILLE 1 0 100 0 17.1 Access standard: 1 Provider within 20 Miles Provider group: PacifiCare Colorado Hospitals PacifiCare Colorado Hospitals - City of Fort Collins Zip code detail information 5.4 City of Fort Collins All employees Average distance Total Total Zip number of number of pat to a choice of County/City code employees providers w wo 1 provider WELD WINDSOR 80550 28 0 100 0 9.1 Subtotal WINDSOR 28 0 100 0 9.1 Subtotal WELD 49 1 100 0 8.3 TOTALS 1,207 5 99 1 5.1 Access standard: 1 Provider within 20 Miles Provider group: PacifiCare Colorado Hospitals PacifiCare Colorado Hospitals - City of Fort Collins Access standard comparison Access standard comparison City of Fort Collins PacifiCare Colorado Hospitals 100% p e 80 r c e n t 60 0 f e m 40 p I 0 Y e e 20 s C 1 2 3 4 5 6 7 8 9 Miles to a choice of providers 1 provider 2 providers 3 providers 10 11 12 13 14 15 4 providers 5 providers Average distance to a choice of PacifiCare Colorado Hospitals Number of providers 1 2 3 4 5 Miles 5.1 10.4 21.0 25.3 28.0 0 City of Fort Collins Managed Care Accessibility Analysis July 27, 1998 A report on the accessibility of the PacifiCare Colorado PPO Primary Care Providers for the employees of City of Fort Collins PacifiCare Colorado PPO Primary Care Providers - City of Fort Collins Table of Contents i Providerlocations....................................................................................................................... 1 PacifiCare Colorado PPO Primary Care Providers Colorado Colorado PPO Service Area Employeelocations..................................................................................................................... 2 City of Fort Collins PacifiCare Colorado PPO Primary Care Providers Colorado 2 Providers within 10 Miles All Colorado PPO Service Area Accessibilitysummary ................................................................................................................. 3 City of Fort Collins PacifiCare Colorado PPO Primary Care Providers 2 Providers within 10 Miles With Accessibilitysummary ................................................................................................................. 4 City of Fort Collins PacifiCare Colorado PPO Primary Care Providers 2 Providers within 10 Miles Without Zipcode detail information.......................................................................................................... 5 City of Fort Collins PacifiCare Colorado PPO Primary Care Providers 2 Providers within 10 Miles All Accessstandard comparison...................................................................................................... 6 City of Fort Collins PacifiCare Colorado PPO Primary Care Providers PacifiCare Colorado PPO Primary Care Providers - City of Fort Collins 1 Provider locations —"-- r'�•" 61 k 1,1v0) L Service area: Colorado PPO Service Area x Multiple provider locations (3) PacifiCare Colorado PPO Primary Care Providers - City of Fort Collins Employee locations - �mpiwyvv wnn access (l, iv4) Provider group: PacifiCare Colorado PPO Primary C (1,150) C Employee without access (13) Access standard: 2 Providers within 10 Miles ❑ Service area: Colorado PPO Service Area PacifiCare Colorado PPO Primary Care Providers - City of Fort Collins 3 Accessibility summary Accessibility analysis specifications Provider group: PacifiCare Colorado PPO Primary Care Providers 1,150 providers at 1,146locations (based on 1,150 records) Employee group: City of Fort Collins 1,207 employees Access standard: 2 Providers within 10 Miles Employees with desired access: 1,194(98.9%) Average distance to a choice of providers for employees with desired access Number of 2 3 4 5 providers Miles 0.8 1.3 1.7 1.9 2.2 Key geographic areas Employees with desired access Total Number Percent Average distance to 2 providers County number of employees LARIMER 1,144 1,133 99 1.3 WELD 49 48 98 2.0 BOULDER 7 7 100 2.1 ADAMS 2 2 100 1.4 JEFFERSON 2 2 100 0.5 ARAPAHOE 1 1 100 0.5 DENVER 1 1 100 0.2 PacifiCare Colorado PPO Primary Care Providers - City of Fort Collins Accessibility summary Accessibility analysis specifications Provider group: PacifiCare Colorado PPO Primary Care Providers 1,150 providers at 1, 146 locations (based on 1,150 records) Employee group: City of Fort Collins 1,207 employees Access standard: 2 Providers within 10 Miles Employees without desired access: 13 (1.1%) Average distance to a choice of providers for employees without desired access Number of providers 1 2 3 4 5 Miles 25.5 31.2 31.8 33.3 33.6 Key geographic areas Employees without desired access Total Number Percent Average distance to 2 providers County number of employees LARIMER 1,144 11 1 26.6 WELD 49 1 2 11.1 DELTA 1 1 100 102.3 PacifiCare Colorado PPO Primary Care Providers - City of Fort Collins Zip code detail information 5.1 City of Fort Collins All employees Total Total Average distance County/City Zip code number of employees number of providers Pct w wo to providers 1 2 ADAMS BROOMFIELD 80020 1 10 100 0 0.8 2.0 80234 1 3 100 0 0.7 0.7 Subtotal BROOMFIELD 2 13 100 0 0.8 1.4 Subtotal ADAMS 2 13 100 0 0.8 1.4 ARAPAHOE AURORA 80014 1 19 100 0 0.3 0.5 Subtotal AURORA 1 19 100 0 0.3 0.5 Subtotal ARAPAHOE 1 19 100 0 0.3 0.5 BOULDER BOULDER 80302 1 2 100 0 0.5 1.5 80304 2 31 100 0 0.2 0.2 Subtotal BOULDER 3 33 100 0 0.3 0.6 LAFAYETTE 80026 1 3 100 0 1.5 1.7 Subtotal LAFAYETTE 1 3 100 0 1.5 1.7 LONGMONT 80501 2 23 100 0 2.1 2.9 Subtotal LONGMONT 2 23 100 0 2.1 2.9 LYONS 80540 1 0 100 0 5.1 5.4 Subtotal LYONS 1 0 100 0 5.1 5.4 Subtotal BOULDER 7 59 100 0 1.7 2.1 DELTA DELTA 81416 1 0 0 100 36.4 102.3 Subtotal DELTA 1 0 0 100 36.4 102.3 Subtotal DELTA 1 0 0 100 36.4 102.3 DENVER DENVER 80252 1 0 100 0 0.1 0.2 Subtotal DENVER 1 0 100 0 0.1 0.2 Access stanaara:z vroviaers within to Miles Provider group: PacifiCare Colorado PPO Primary Care Providers Cihl of Fort Collins Proposal to Provide Medical Benefits a Cover Letter a Medical Managed Care a Third Party Administration a Utilization Review (UR) Services a Stop -Loss Insurance a Prescription Drug Plan a General Information a Attachments July 29, 1998 Section I Section 2 Section 3 Section 4 Section 5 Section 6 Section 7 Section S PacffiCcolwe 0 3. Are there any forms of treatment that cannot be provided by your hospital network? If so, which ones? No, if treatment is not available in Fort Collins, PacifiCare will make arrangements through the Denver network. If services are limited in the Denver area, PacifiCare will make them available as required. This is evaluated on a case -by -case basis. 4. Please submit a list of negotiated rates for all participating health care facilities in your network. Please note that the preference is DRGs or per diems. We understand that this information is proprietary, therefore, we agree to maintain confidentiality and will use this information solely for the purposes described herein. Hospital provider contracts are established using per diem, per diem with stop loss and discount arrangements. Traditional reimbursement is as follows: Hospital Inpatient 33 % 67 % Hospital Outpatient 100% Primary Care Physician 18% 82% Specialist Physician 42 % 55 % 3 % Medical Group IPA 100% Independent Laboratory 100% Independent radiolo is centers 100% Independent surgery centers 46 % 54 % Independent urgent care centers 100% Pharmacies 100% Podiatrists 100% Durable medical equipment roviders 100% Home infusion therapy providers 100% Home nursing 100 % Mental health providers 100% Chemical dependency roviders 100% Eye Network 100% 5. Are there additional discounts available to the group for "prompt payment"? If so, please define "prompt payment" and state amount of discount. If a prompt payment clause is present in the contract, PacifiCare's computer system automatically honors the agreement with payment of claims processing. 6. How long are these hospital rates guaranteed? Are you able to deliver multiple year agreements with increases tied to economic indicators? Contracts do not guarantee rates. Poudre Valley is a one year contract, fully insured business is capitated in a two year agreement. The rates are tied to utilization and historical cost. 10 PacifiCare Colorado PPO Primary Care Providers - City of Fort Collins Zip code detail information 5.2 City of Fort Collins All employees Total Total Average distance County/City Zip code number of employees number of providers Pct w 100 wo 0 to providers 1 0.1 2 Subtotal DENVER 1 0 0.2 JEFFERSON ARVADA 80003 1 5 100 0 0.4 0.5 Subtotal ARVADA 1 5 100 0 0.4 0.5 DENVER 80215 1 12 100 0 0.4 0.5 Subtotal DENVER 1 12 100 0 0.4 0.5 Subtotal JEFFERSON 2 17 100 0 0.4 0.5 LARIMER BELLVUE 80512 16 0 100 0 3.5 4.9 Subtotal BELLVUE 16 0 100 0 3.5 4.9 BERTHOUD 80513 1 3 100 0 0.8 3.0 Subtotal BERTHOUD 1 3 100 0 0.8 3.0 DRAKE 80515 1 0 100 0 4.5 5.0 Subtotal DRAKE 1 0 100 0 4.5 5.0 ESTES PARK 80517 2 6 100 0 0.5 0.6 Subtotal ESTES PARK 2 6 100 0 0.5 0.6 FORT COLLINS 80521 195 0 100 0 1.0 1.4 80522 11 0 100 0 1.3 1.5 80524 184 39 100 0 0.2 0.8 80525 248 12 100 0 0.8 1.2 80526 314 15 100 0 0.6 1.1 80527 7 0 100 0 0.4 1.9 Subtotal FORT COLLINS 959 66 100 0 0.7 1.1 LAPORTE 80535 44 0 100 0 1.7 2.0 Subtotal LAPORTE 44 0 100 0 1.7 2.0 LIVERMORE 80536 8 0 0 100 25.7 26.1 80545 3 0 0 100 27.1 28.1 Subtotal LIVERMORE 11 0 0 100 26.1 26.6 nuUWb� bral luarU. c rruviaem wimrn iU napes Provider group: PacifiCare Colorado PPO Primary Care Providers PacifiCare Colorado PPO Primary Care Providers - City of Fort Collins Zip code detail information City of Fort Collins 5.3 All employees Total Total Average distance County/City Zip code number of employees number of providers pct w wo to providers 1 2 LARIMER LOVELAND 80537 32 11 100 0 0.5 1.3 80538 42 18 100 0 0.5 1.3 80539 2 0 100 0 1.3 2.6 Subtotal LOVELAND 76 29 100 0 0.5 1.3 MASONVILLE 80541 2 0 100 0 1.3 2.6 Subtotal MASONVILLE 2 0 100 0 1.3 2.6 TIMNATH 80547 3 0 100 0 0.2 2.1 Subtotal TIMNATH 3 0 100 0 0.2 2.1 WELLINGTON 80549 29 0 100 0 3.2 3.8 Subtotal WELLINGTON 29 0 100 0 3.2 3.8 Subtotal LARIMER 1,144 104 99 1 1.1 1.6 WELD AULT 80610 2 1 100 0 0.7 4.3 Subtotal AULT 2 1 100 0 0.7 4.3 EATON 80615 5 1 100 0 1.2 2.6 Subtotal EATON 5 1 100 0 1.2 2.6 EVANS 80620 2 0 100 0 1.2 1.5 Subtotal EVANS 2 0 100 0 1.2 1.5 GREELEY 80631 4 49 100 0 0.7 1.1 80634 4 2 100 0 1.3 1.8 Subtotal GREELEY 8 51 100 0 1.0 1.4 JOHNSTOWN 80534 1 1 100 0 0.5 4.8 Subtotal JOHNSTOWN 1 1 100 0 0.5 4.8 PIERCE 80650 2 0 100 0 3.5 8.3 Subtotal PIERCE 2 0 100 0 3.5 8.3 PLATTEVILLE 80651 1 0 0 100 8.4 11.1 Subtotal PLATTEVILLE 11 0 1 0 1100 1 8.4 11.1 muwbb SlGnuitra: c rroviaers wimin lu Mlles Provider group: PacifiCare Colorado PPO Primary Care Providers PacifiCare Colorado PPO Primary Care Providers - City of Fort Collins Zip code detail information 5.4 City of Fort Collins All employees Total Total Average distance County/City Zip code number of employees number of providers Pct w wo to providers 1 2 WELD WINDSOR 80550 28 5 100 0 0.7 1.4 Subtotal WINDSOR 28 5 100 0 0.7 1.4 Subtotal WELD 49 59 98 2 1.1 2.2 TOTALS 1,207 271 99 1 1.1 1.7 t 3 �ccass SCdnaara: z r-roviaers wimin lu wes Provider group: PacifiCare Colorado PPO Primary Care Providers PacifiCare Colorado PPO Primary Care Providers - City of Fort Collins 6 Access standard comparison Access standard comparison City of Fort Collins PacifiCare Colorado PPO Primary Care Providers 100% P e 80 r c e n t 60 0 f e m 40 p I 0 Y e e 20 s 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Miles to a choice of providers 1 provider 2 providers 3 providers 4 providers 5 providers Average distance to a choice of PacifiCare Colorado PPO Primary Care Providers Number of providers 1 2 3 4 5 Miles 1.1 1.7 2.0 2.3 2.5 City of Fort Collins Managed July 27, 1998 Care Accessibility Analysis A report on the accessibility of the PacifiCare Colorado PPO OB/GYNs for the employees of City of Fort Collins PacifiCare Colorado PPO OB/GYNs - City of Fort Collins Table of Contents Providerlocations....................................................................................................................... 1 PacifiCare Colorado PPO OB/GYNs Colorado Colorado PPO Service Area Employeelocations..................................................................................................................... 2 City of Fort Collins PacifiCare Colorado PPO OB/GYNs Colorado 2 Providers within 10 Miles All Colorado PPO Service Area Accessibilitysummary ................................................................................................................. 3 City of Fort Collins PacifiCare Colorado PPO OB/GYNs 2 Providers within 10 Miles With Accessibilitysummary ................................................................................................................. 4 City of Fort Collins PacifiCare Colorado PPO OB/GYNs 2 Providers within 10 Miles Without Zipcode detail information.......................................................................................................... 5 City of Fort Collins PacifiCare Colorado PPO OB/GYNs 2 Providers within 10 Miles All Accessstandard comparison...................................................................................................... 6 City of Fort Collins PacifiCare Colorado PPO OB/GYNs PacifiCare Colorado PPO OB/GYNs - City of Fort Collins 1 Provider locations • Provider locations ❑ Service area: Colorado PPO Service Area PacifiCare Colorado PPO OB/GYNs - City of Fort Collins Employee locations • employee with access (1,182) Provider group: PacifiCare Colorado PPO OB/GYNs (285) o Employee without access (25) Access standard: 2 Providers within 10 Miles ❑ Service area: Colorado PPO Service Area PacifiCare Colorado PPO OB/GYNs - City of Fort Collins Accessibility summary Accessibility analysis specifications Provider group: PacifiCare Colorado PPO OB/GYNs 285 providers at 285 locations (based on 285 records) Employee group: City of Fort Collins 1,207 employees Access standard: 2 Providers within 10 Miles Employees with desired access: 1,182 (97.9%) Average distance to a choice of providers for employees with desired access Number of providers 2 3 4 5 Miles 2.8 3.6 4.1 4.7 5.1 Key geographic areas Employees with desired access Total Average distance number of County employees Number Percent to 2 providers LARIMER 1,144 1,123 98 3.6 WELD 49 46 94 4.5 BOULDER 7 7 100 4.4 ADAMS 2 2 100 2.5 JEFFERSON 2 2 100 1.7 ARAPAHOE 1 1 100 2.6 DENVER 1 1 100 0.9 PacifiCare Colorado PPO OB/GYNs - City of Fort Collins 4 Accessibility summary Accessibility analysis specifications Provider group: PacifiCare Colorado PPo osiGYNs 285 providers at 285 locations (based on 285 records) Employee group: city of Fort Collins 1,207 employees Access standard: 2 Providers within 10 Miles Employees without desired access: 25 (2.1%) Average distance to a choice of providers for employees without desired access Number of providers 2 3 4 5 Miles 24.6 27.2 27.8 28.8 29.5 Key geographic areas County Total number of employees Employees without desired access Number Percent Average distance to 2 providers LARIMER WELD DELTA 1,144 49 1 21 3 1 2 6 100 23.2 12.6 155.5 7. What has been the average rate of increase for participating facilities since you first became operational? For Poudre Valley, the percent of billed charges has gone from 96% in 1994 to 90% in 1998. This is the rate which would be billed for self -funded membership, not Fort Collins PMG membership. 8. Are there any ancillary services not contracted? Please explain. (i.e., emergency room physicians, durable medical equipment, hospice, rehabilitation, laboratory, home health care, etc.) Please identify negotiated terms of those under contract. All ancillary services identified are contracted through either PMG or PacifiCare. 9. Please describe the liability insurance requirements for your contracted hospitals. Liability insurance requirements are $1,000,000 per occurrence and $3,000,000 aggregate. 10. Please enclose a sample hospital contract. Proprietary information. D. Utilization Management/Ouality Assurance Please respond to the following questions about your organization's internal utilization management and quality assurance programs. The City is concurrently seeking proposals for utilization management services, and your network will be required to interface with the selected organization. Please provide a detailed description of your utilization management and quality assurance programs, how they operate and the protocols and criteria used. Please see Utilization Program Description attachment and Quality Improvement Program Description attachment. 2. Describe in detail how your organization determines the medical necessity of medical treatment. What types of standardized quality measurement systems do you use? PacifiCare uses standards as a reference, although we focus more on the individual needs of a patient to determine medical necessity. We receive updated national standards on a periodic basis. Medical necessity is defined in our EPO/POS plans with the following language: Appropriate health services and/or supplies which are determined by PacifiCare of Colorado to be necessary for the diagnosis and treatment of basic health needs of the individual. To be appropriate, the service or supply must conform to the approved and generally accepted standards of medical or surgical practice when and where the service or supply is ordered. • Determination of medical necessity is done on a case by case basis. 11 PacifiCare Colorado PPO OB/GYNs - City of Fort Collins Zip code detail information 5.1 City of Fort Collins All employees Total Total Average distance Zip number of number of pct to providers 1 2 County/City code employees providers w wo ADAMS BROOMFIELD 80020 1 1 100 0 1.9 3.3 80234 1 2 100 0 0.4 1.7 Subtotal BROOMFIELD 2 3 100 0 1.2 2.5 Subtotal ADAMS 2 3 100 0 1.2 2.5 ARAPAHOE AURORA 80014 1 0 100 0 1.5 2.6 Subtotal AURORA 1 0 100 0 1.5 2.6 Subtotal ARAPAHOE 1 0 100 0 1.5 2.6 BOULDER BOULDER 80302 1 0 100 0 3.1 4.1 80304 2 11 100 0 0.4 0.7 Subtotal BOULDER 3 11 100 0 1.3 1.8 LAFAYETTE 80026 1 0 100 0 4.2 4.5 Subtotal LAFAYETTE 1 0 100 0 4.2 4.5 LONGMONT 80501 2 3 100 0 5.8 7.5 Subtotal LONGMONT 2 3 100 0 5.8 7.5 LYONS 80540 1 0 100 0 5.3 5.9 Subtotal LYONS 1 0 100 0 5.3 5.9 Subtotal BOULDER 7 14 100 0 3.6 4.4 DELTA DELTA 81416 1 0 0 100 152.7 155.5 Subtotal DELTA 1 0 0 100 152.7 155.5 Subtotal DELTA 1 0 0 100 152.7 155.5 DENVER DENVER 80252 1 0 100 0 0.1 0.9 Subtotal DENVER 1 0 100 0 0.1 0.9 I i Hccess stanaara: ;e vroviaers witnin iu wes Provider group: PacifiCare Colorado PPO OB/GYNs PacifiCare Colorado PPO OB/GYNs - City of Fort Collins Zip code detail information 5.2 City of Fort Collins All employees Total Total Average distance Zip number of number of pct to providers 1 2 0.1 0.9 County/City code employees providers w 100 wo 0 Subtotal DENVER 1 0 JEFFERSON ARVADA 80003 1 0 100 0 1.8 1.9 Subtotal ARVADA 1 0 100 0 1.8 1.9 DENVER 80215 1 0 100 0 1.2 1.5 Subtotal DENVER 1 0 100 0 1.2 1.5 Subtotal JEFFERSON 2 0 100 0 1.5 1.7 LARIMER BELLVUE 80512 16 0 75 25 8.1 9.2 Subtotal BELLVUE 16 0 75 25 8.1 9.2 BERTHOUD 80513 1 0 100 0 7.4 7.9 Subtotal BERTHOUD 1 0 100 0 7.4 7.9 DRAKE 80515 1 0 100 0 3.7 5.1 Subtotal DRAKE 1 0 100 0 3.7 5.1 ESTES PARK 80517 2 1 0 100 1.1 17.0 Subtotal ESTES PARK 2 1 0 100 1.1 17.0 FORT COLLINS 80521 195 0 100 0 3.0 4.2 80522 11 0 100 0 3.6 4.8 80524 184 3 99 1 2.6 3.3 80525 248 10 100 0 0.9 1.8 80526 314 0 100 0 3.4 3.9 80527 7 0 100 0 1.7 1.8 Subtotal FORT COLLINS 959 13 100 0 2.5 3.3 LAPORTE 80535 44 0 100 0 6.4 7.3 Subtotal LAPORTE 44 0 100 0 6.4 7.3 LIVERMORE 80536 8 0 0 100 32.7 33.3 80545 3 0 0 100 28.9 34.1 Subtotal LIVERMORE 11 0 0 100 31.7 33.5 41 I c vccess standard: 2 Providers within 10 Miles Provider group: PacifiCare Colorado PPO OB/GYNs PacifiCare Colorado PPO OB/GYNs - City of Fort Collins Zip code detail information 5.3 City of Fort Collins All employees Total Total Average distance Zip number of number of Pct to providers 1 2 County/City code employees providers w wo LARIMER LOVELAND 80537 32 0 100 0 2.9 3.3 80538 42 7 100 0 1.7 2.5 80539 2 0 100 0 0.6 1.4 Subtotal LOVELAND 76 7 100 0 2.2 2.8 MASONVILLE 80541 2 0 100 0 0.6 1.4 Subtotal MASONVILLE 2 0 100 0 0.6 1.4 TIMNATH 80547 3 0 100 0 1.9 2.1 Subtotal TIMNATH 3 0 100 0 1.9 2.1 WELLINGTON 80549 29 0 93 7 7.0 8.4 Subtotal WELLINGTON 29 0 93 7 7.0 8.4 Subtotal LARIMER 1,144 21 98 2 3.1 3.9 WELD AULT 80610 2 0 100 0 8.4 8.5 Subtotal AULT 2 0 100 0 8.4 8.5 EATON 80615 5 0 100 0 4.7 5.1 Subtotal EATON 5 0 100 0 4.7 5.1 EVANS 80620 2 0 100 0 1.2 2.1 Subtotal EVANS 2 0 100 0 1.2 2.1 GREELEY 80631 4 9 100 0 1.5 2.4 80634 4 0 100 0 2.6 3.6 Subtotal GREELEY 8 9 100 0 2.0 3.0 JOHNSTOWN 80534 1 0 100 0 8.2 9.2 Subtotal JOHNSTOWN 1 0 100 0 8.2 9.2 PIERCE 80650 2 0 0 100 12.4 12.4 Subtotal PIERCE 2 0 0 100 12.4 12.4 PLATTEVILLE 80651 1 0 0 100 11.9 13.2 Subtotal PLATTEVILLE I 1 1 0 0 100 11.9 13.2 Access standard: 2 Providers within 10 Miles Provider group: PacifiCare Colorado PPO OB/GYNs PacifiCare Colorado PPO OB/GYNs - City of Fort Collins 5.4 Zip code detail information City of Fort Collins County/City Zip code Total number of employees Total number of providers All employees pct w wo Average distance to providers 1 2 WELD WINDSOR Subtotal WINDSOR Subtotal WELD 80550 28 28 49 0 0 9 100 100 94 0 0 6 3.1 3.1 3.9 4.5 4.5 5.0 TOTALS 1,207 47 98 2 3.2 4.1 Access standard: 2 Providers within 10 Miles Provider group: PacifiCare Colorado PPO OB/GYNs PacifiCare Colorado PPO OB/GYNs - City of Fort Collins Access standard comparison Access standard comparison City of Fort Collins PacifiCare Colorado PPO OB/GYNs 100% p e 80 r c e n t 60 0 f e m 40 p 0 Y e e 20 s 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Miles to a choice of providers 1 provider 2 providers 3 providers 4 providers 5 providers Average distance to a choice of PacifiCare Colorado PPO OB/GYNs Number of providers 2 3 4 5 Miles 3.2 4.1 4.6 5.2 5.6 R City of Fort Collins Managed Care Accessibility Analysis July 27, 1998 A report on the accessibility of the PacifiCare Colorado PPO Hospitals for the employees of City of Fort Collins PacifiCare Colorado PPO Hospitals - City of Fort Collins i Table of Contents Providerlocations....................................................................................................................... 1 PacifiCare Colorado PPO Hospitals Colorado Colorado PPO Service Area Employeelocations..................................................................................................................... 2 City of Fort Collins PacifiCare Colorado PPO Hospitals Colorado 1 Provider within 20 Miles All Colorado PPO Service Area Accessibilitysummary ................................................................................................................. 3 City of Fort Collins PacifiCare Colorado PPO Hospitals 1 Provider within 20 Miles With Accessibilitysummary ................................................................................................................. 4 City of Fort Collins PacifiCare Colorado PPO Hospitals 1 Provider within 20 Miles Without Zipcode detail information.......................................................................................................... 5 City of Fort Collins PacifiCare Colorado PPO Hospitals 1 Provider within 20 Miles All Access standard comparison...................................................................................................... 6 City of Fort Collins PacifiCare Colorado PPO Hospitals PacifiCare Colorado PPO Hospitals - City of Fort Collins Provider locations • Provider locations ❑ Service area: Colorado PPO Service Area PacifiCare Colorado PPO Hospitals - City of Fort Collins 2 Employee locations • Employee with access (1,199) Provider group: PacifiCare Colorado PPO Hospitals (63) a Employee without access (8) Access standard: 1 Provider within 20 Miles ❑ Service area: Colorado PPO Service Area PacifiCare Colorado PPO Hospitals - City of Fort Collins 3 Accessibility summary Accessibility analysis specifications Provider group: PacifiCare Colorado PPo Hospitals 63 providers at 63 locations (based on 63 records) Employee group: City of Fort Collins 1,207 employees Access standard: 1 Provider within 20 Miles Employees with desired access: 1,199 (99.3%) Average distance to a choice of providers for employees with desired access Number of providers t 2 3 4 5 Miles 6.9 11.8 17.4 21.7 24.7 Key geographic areas Employees with desired access Total Average distance number of County employees Number Percent to 1 provider LARIMER 1,144 1,136 99 6.9 WELD 49 49 100 7.0 BOULDER 7 7 100 4.0 ADAMS 2 2 100 4.8 JEFFERSON 2 2 100 3.0 ARAPAHOE 1 1 100 3.6 DELTA 1 1 100 1.3 DENVER 1 1 100 1.2 • Medically necessary services must be consistent with the diagnosis of, and prescribed course of treatment for the patient's condition. • Medically necessary services or supplies are required for reasons other than the convenience of the patient or of his/her physician. • Medically necessary services are not required solely for custodial, comfort or maintenance reasons. • Medically necessary services must be performed in the most cost effective setting appropriate for the condition. The fact that a physician may prescribe, order, recommend or approve a service or supply does not, by itself, make the service or supply medically necessary or a covered expense, even though it may be specifically listed as an exclusion. PPO language regarding medical necessity is as follows: Medical Necessity -- The benefits of the Policy are provided only for the services and supplies that are Medically Necessary as determined by PacifiCare and/or pursuant to the Utilization Review provisions of this Policy. The service and/or supplies provided by a hospital, physician, surgeon or other provider which are: appropriate for the diagnosis, or the direct care and treatment of a condition, illness or injury; and in accordance with the standards of good medical practice in this community; and not primarily for the convenience of the insured or personal preference as the insured or the convenience of the insured individual's physician and surgeon or other provider or caretaker; and the most appropriate supply or level of service which can safely be provided. 3. Is there a review committee to monitor quality of care? Who is on the committee and how often do they meet? Yes, PaciflCare has a Peer Review Committee made up of several contracted physicians and specialists. Potential quality of care issues are reviewed by the Peer Review Committee once every two months. PacifiCare has a Nursing Peer Review Committee made up of Registered Nurses to also review potential quality of care concerns involving nursing and ancillary care in a facility or ambulatory service. The committee conducts individual case review, tracks and trends data, obtain action plans as needed and reports activities to the Physician Peer Review Committee. This committee meets monthly. 4. Does the managed care program have a formal procedure for addressing member grievances? If so, please explain. By PacifiCare definition, a grievance is a written concern from a member with a perceived quality of care issue. Member grievances with potential for a clinical quality of care issue are investigated by Medical Management Staff. The investigation includes review by: a registered nurse; a physician; and depending on the findings in the case, the PacifiCare Peer Review Committee. 12 PacifiCare Colorado PPO Hospitals - City of Fort Collins 4 Accessibility summary Accessibility analysis specifications Provider group: PacifiCare Colorado PPo Hospitals 63 providers at 63 locations (based on 63 records) Employee group: city of Fort Collins 1,207 employees Access standard: 1 Provider within 20 Miles Employees without desired access: 8 (0.7%) Average distance to a choice of providers for employees without desired access Number of providers 1 2 3 4 5 Miles 30.7 37.7 40.4 52.1 53.6 Key geographic areas Employees without desired access Total Average distance number of County employees Number Percent to 1 provider LARIMER 1,144 8 1 30.7 PacifiCare Colorado PPO Hospitals - City of Fort Collins Zip code detail information 5.1 City of Fort Collins All employees Total Total Average distance County/City Zip code number of employees number of providers Pct w wo to a choice of 1 provider ADAMS BROOMFIELD 80020 1 0 100 0 5.2 80234 1 0 100 0 4.3 Subtotal BROOMFIELD 2 0 100 0 4.8 Subtotal ADAMS 2 0 100 0 4.8 ARAPAHOE AURORA 80014 1 0 100 0 3.6 Subtotal AURORA 1 0 100 0 3.6 Subtotal ARAPAHOE 1 0 100 0 3.6 BOULDER BOULDER 80302 1 0 100 0 5.8 80304 2 1 100 0 1.6 Subtotal BOULDER 3 1 100 0 3.0 LAFAYETTE 80026 1 0 100 0 5.4 Subtotal LAFAYETTE 1 0 100 0 5.4 LONGMONT 80501 2 3 100 0 4.1 Subtotal LONGMONT 2 3 100 0 4.1 LYONS 80540 1 0 100 0 5.4 Subtotal LYONS 1 0 100 0 5.4 Subtotal BOULDER 7 4 100 0 4.0 DELTA DELTA 81416 1 1 100 0 1.3 Subtotal DELTA 1 1 100 0 1.3 Subtotal DELTA 1 1 100 0 1.3 DENVER DENVER 80252 1 0 100 0 1.2 Subtotal DENVER 1 0 100 0 1.2 i Access standard: 1 Provider within 20 Miles Provider group: PacifiCare Colorado PPO Hospitals PacifiCare Colorado PPO Hospitals - City of Fort Collins Zip code detail information 5.2 City of Fort Collins All employees Average distance Total Total Zip number of number of Pct to a choice of County/City code employees providers w wo 1 provider Subtotal DENVER 1 0 100 0 1.2 JEFFERSON ARVADA 80003 1 0 100 0 3.8 Subtotal ARVADA 1 0 100 0 3.8 DENVER 80215 1 0 100 0 2.2 Subtotal DENVER 1 0 100 0 2.2 Subtotal JEFFERSON 2 0 100 0 3.0 LARIMER BELLVUE 80512 16 0 100 0 7.4 Subtotal BELLVUE 16 0 100 0 7.4 BERTHOUD 80513 1 0 100 0 7.6 Subtotal BERTHOUD 1 0 100 0 7.6 DRAKE 80515 1 0 100 0 5.1 Subtotal DRAKE 1 0 100 0 5.1 ESTES PARK 80517 2 1 100 0 1.0 Subtotal ESTES PARK 2 1 100 0 1.0 FORT COLLINS 80521 195 0 100 0 7.1 80522 11 0 100 0 6.7 80524 184 1 100 0 6.4 80525 248 0 100 0 8.3 80526 314 0 100 0 7.0 80527 7 0 100 0 8.6 Subtotal FORT COLLINS 959 1 100 0 7.2 LAPORTE 80535 44 0 100 0 4.1 Subtotal LAPORTE 44 0 100 0 4.1 LIVERMORE 80536 8 0 38 62 26.1 80545 3 0 0 100 28.5 Subtotal LIVERMORE 11 0 27 73 26.8 g Y Access standard: 1 Provider within 20 Miles Provider group: PacifiCare Colorado PPO Hospitals PacifiCare Colorado PPO Hospitals - City of Fort Collins Zip code detail information City of Fort Collins 5.3 Total Total All employees Average distance Zip number of number of Pct to a choice of County/City code employees providers w wo 1 provider LARIMER LOVELAND 80537 32 0 100 0 5.4 80538 42 1 100 0 4.4 80539 2 0 100 0 2.1 Subtotal LOVELAND 76 1 100 0 4.7 MASONVILLE 80541 2 0 100 0 2.1 Subtotal MASONVILLE 2 0 100 0 2.1 TIMNATH 80547 3 0 100 0 8.4 Subtotal TIMNATH 3 0 100 0 8.4 WELLINGTON 80549 29 0 100 0 5.5 Subtotal WELLINGTON 29 0 100 0 5.5 Subtotal LARIMER 1,144 3 99 1 7.1 WELD AULT 80610 2 0 100 0 11.1 Subtotal AULT 2 0 100 0 11.1 EATON 80615 5 0 100 0 8.7 Subtotal EATON 5 0 100 0 8.7 EVANS 80620 2 0 100 0 7.4 Subtotal EVANS 2 0 100 0 7.4 GREELEY 80631 4 1 100 0 8.8 80634 4 0 100 0 4.3 Subtotal GREELEY 8 1 100 0 6.6 JOHNSTOWN 80534 1 0 100 0 8.2 Subtotal JOHNSTOWN 1 0 100 0 8.2 PIERCE 80650 2 0 100 0 14.5 Subtotal PIERCE 2 0 100 0 14.5 PLATTEVILLE 80651 1 0 100 0 19.4 Subtotal PLATTEVILLE 1 0 100 0 19.4 Access standard: 1 Provider within 20 Miles Provider group: PacifiCare Colorado PPO Hospitals PacifiCare Colorado PPO Hospitals - City of Fort Collins Zip code detail information 5.4 City of Fort Collins All employees Average distance Total Total Zip number of number of Pct to a choice of County/City code employees providers w wo 1 provider WELD WINDSOR 80550 28 0 100 0 5.5 Subtotal WINDSOR 28 0 100 0 5.5 Subtotal WELD 49 1 100 0 7.0 TOTALS 1,207 9 99 1 7.0 Access standard: 1 Provider within 20 Miles Provider group: PacifiCare Colorado PPO Hospitals PacifiCare Colorado PPO Hospitals - City of Fort Collins 6 Access standard comparison Access standard comparison City of Fort Collins PacifiCare Colorado PPO Hospitals 100% P e 80 r c e n t 60 - - 0 f e m 40 P I 0 Y e e 20 s 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Miles to a choice of providers 1 provider 2 providers 3 providers 4 providers 5 providers Average distance to a choice of PacifiCare Colorado PPO Hospitals Number of providers 1 2 3 4 5 Miles 7.0 11.9 17.5 21.9 24.9 No Text Disruptive Analysis - Larimer County 9 a E V Family Practice 119 Total Participator Count of Specialty Percent Paa6Care PPO $loans Lake PPO 79 86 66.4 % 72.3 % Payer ■ coua of Sfecatty ® TOW Internal Medicine 20 Total Participator Count of Specialty Percent Padificare PPO Sloan Lake PPO 91 i6l 4&0 % 75.0 % ■ crone of sW.My ® Taw Pediatrics 19 Total Participator Courrt of Specialty Percent PaeficorePPO SWns Lake PPO 73 15 6$.4% 73.9 % Payer ■ court of S09"N ® Taw W2219$ Pape S"W. AI9W*-iifri Owfftgo*&W Disruptive Analysis Larimer County PaeifiCare PPO Sloans Lake PPO Abbey, David M. Internal Medicine / Alessi, Grace Internal Medicine ■ ■ David K InternalAllen, orne Thomas J. Family■ ■ n' FE Scott I-amiiy Practice■ / Amour, Ross W. Family Practice ■ ■ 5ailey Jr.. Austin 0. I -amity Practice■ ■ Ueard. Donald Y. atrres ■ ■ Bender, Edward L Familywoe ■ ■ Bermingham. FSWP.- Family Practice-933K Richard K. iatncs ■ ■ oman, Steven D. FamilyPractice ■ ■ Brower, Annette A. Familyrawce ■ / tsumham. Unda 71 Familyrawoe ■ James F. internaliane ■ ■ Anthony Family Practice ■ ■ Carlson, Hillis Watin Family Practice■ Carroll, Cory 0. Farmy Practice ■ ■ rson Jr.. Frank K. Familyrachce ■ ■ e G. familyracaoe / Coburn. Thomas C. Familyrac ■ C411ins. Thomas J. Famityrawoe ■ n 0. PedletlICS ■ ■ ranor. John Oavid FaMily ■ ■ Dinforth Ill, James C, Familyrawoe Ue oung, Uouguis B. amr rawce ■ / DO la Torre. PebbeCa A. Family Practicet:Wy ■ ■ tuaw. max A. Pediatrics / ■ n, Lome Family Fracbee ■ Ferguson,a rawee ■ ■ s 3acipmene, c. FamilyPractice / tnckman, Cad Elm Family Practice ■ ■ Geppot o .— Family Pracowme ■ Cynthia L Family■ ■ u, DinM E. Pediatrics■ reY. April K Family Practice- Urosboll.Family ice ■ ■ h ratros ■ ■ Hagan, John J. Internalcane ■Mile ■ Y. Mark A. Family/ anon, Vaughn W. ratryoq / ■ mson, William L InternalMedicine ■ rggrns Jane A. FaRVractroe ■ om urg, Robert C. Internal MedicineHowell. ■ Down K. Family Practice ■ owton, James A. r ■ ■ .SMW AGWO-PO 400ron 7RaM Disruptive Analysis Larimer County PaCW.are PPO Sloans Lake PPO Hughes, Andrew G. Family Practice ■ ■ Jinich, Laniel U. Family PrActice ■ ■ nson, PichardW. internalmane ■ ■ Kasenberg. Thomas a rawce ■ ■ N. Family Pracme ■ ■ rre FarrWy Practice ■ ■ anti Laurence 1. Family Practice ■ ■ Lee. Jeffrey L. PiRy Practice ■ ■ LOPM Joseph M. army Precow■ ■ Lopez Jr.. William L internalcane ■ Lynch,ntema cane ■ ac Donald. UOIA A. Family■ ■ Maly, Y J. Family■ c Ginrus. James is. 176210ig- ■ ■ Jeanneffe Y. Familyacne ■ ■ Merkel. Lawrence A. Family Practice ■ ■ Mid0iftrooK, Tammy T. piagavics ■ ■ er. Richard & Familly■ ■ Murphy,nce t. I-SmIly, Practice■ ■ Nevrivy. Thomas E. FamilyPractice ■ ■ Thomas W. Familyraetice ■ ■ Nye, Bret Familyra ■ ■ Ottowright. amdy Pracbm ■ ■ Y L. Irftmalicine ■ Paddack,ami cace ■ ■ Faisley. Jan E. Pedtav= ■ ■ Parliment, Joel Internalmane ■ PauMn, Mark Mc Clure Family Fracittice■ ■ Mccaro. John C. Family Prac6ce■ ■ Timothy amr ce ■ mMana, Wchael u. Pediatrft- Keents, Willisim J. Family Pracotlowe ■ ■ nsone ■ ■ o n, ■ ■ ■ ■ Kule. Ingridam wce ■ ■ a r- mer, Mary RM f-armly Pracuce■ amue+rson, Soon J. Isarmly Practice■ ■ ur tr --Family ftafice ■ ■ NcanLon, Charlone u. Imemaiicine ■ ■ R. arm ■ ■ ami ra c ■ ■ Seewn. James F. Farm racnce ■ ■ Ronald army racw* ■ ■ ,ineppard-Madden. Me N. FamilyPractice ■ ■ I-amilly Vraaxe ■ ■ m "MdY PraCboe ■ ■ amen Family, PffcticeStW ■ ■ ens Jr.. 1-loya V. I-amily Pracitice ■ ■ 5. Please provide copies of your standard reports applicable to utilization management and quality assurance. A complete Plan HEDIS report will be forwarded to the City of Fort Collins in third quarter l"8. E. Administration/Fees Are any administrative costs for your network paid for via a physician withhold? If so, please describe in detail. PacifiCare does not directly apply physician withholds. 2. Would your organization consider a multiple year fee guarantee? If yes, please state monthly fee(s) per member. No, fees are not guaranteed for more than one year. 3. This RFP requires that the fees you quote for the City's 1999 plan year be guaranteed for the 12-month period. Will your organization comply with this requirement? Yes, fees quoted in this RFP are guaranteed for a 12-month period. 4. Are there any additional costs or fees which are not covered by the fees outlined in your fee quotation? F. Legal No, additional costs and fees not outlined do not exist. Will you agree to a contract provision requiring your organization to provide at least a 120-day written notice to the City prior to the renewal dates of the contract of a change in rates? Yes, PacifiCare agrees to a contract provision requiring a 120-day written notice prior to the renewal dates of the contract if there is a change in rates. 2. Are you willing to enter into a hold harmless agreement? Please explain. PacifiCare's provider contracts contain hold harmless language that protects members from liability for unpaid bills. 3. Will you agree to the following contract provision for termination of agreement? Termination of Agreement. This Agreement may be terminated at any time by mutual consent of both parties. This Agreement may be terminated by either party at any time upon sixty (60) days written notice to the other party. Yes, PacifiCare agrees to this contract provision. 13 Disruptive Analysis Larimer County PacMarc PPO Slears lake PPO Stoddard, Andrew P. Family Practice ■ ■ Su&Wan. Donna L Family Practice ■ ■ Sullivan, VVIIIIam J. ■ ■ Surithiankar. ru(Lens) am. ice ■ ■ Robert J. Internaliune ■ ■ Kman, William J. FamilyTh*=W, Milford h. I -amity■ Worsen, Steven J. Family Practice ■ ^ L pedlatift■ ■ ichael K Family Pf2=M■ ■ Unger, amr y Practice ■ ■ Valley. e L Famictloe ■ ■ Van Farawre, amt ■ ■ an WWOR. GUY P. Familyce ■ ■ Waller. Kathleen Faintly■ uouglas S. Internalcine ■ ■ eFamily Practice ■ ■ We"isner. M L. pod-olnes ■ ■ Vkfingaze, DanaMedicine ■ Woftet. Susan Family■ MORE. Elizatietri n Pediatnes ■ emm, Stephen J. F-amily Practice■ ■ A Disruption Analysis was not completed for the EPO/POS as PacifiCare is the existing network. No Text PACIFICARE, OF COLORADO UTILIZATION MANAGEMENT PROGRAM DESCRIPTION 1998 Previous UM Program Approval Dates: (insert date), approved Medical Management Sub -committee (insert date), approved QI Committee (insert date), approved Board of Directors (insert date), approved Medical Management Sub -committee (insert date), approved QI Committee (insert date), approved Board of Directors NOTE: List only those committees responsible for approval of the Plan 's UMPD. Show two years of approval history. Be sure to have copies ofprior UMPD's and minutes to substantiate dates. \DelegationTaskForce\UMProgramDescription. doc PACIFICARE OF COLORADO UTILIZATION MANAGEMENT PROGRAM DESCRIPTION 1998 Table of Contents Section Page No. 1.0 Introduction................................................... 4 2.0 Purpose........................................................... 4 3.0 Mission........................................................... 4 4.0 Goals and Objectives ........................................... 4 5.0 Program Scope and Content .................................. 5 5.1 Monitoring and Evaluation ................................. 6 5.2- Data Sources ................................................. 6 5.3 Indicators.................................................... 7 5.4 Criteria........................................................ 8 5.5 Authorization Decisions .................................... 8 5.6 Denial/Appeals.............................................. 8 5.7 Corrective Action/Follow-up .............................. 9 5.8 Prioritization.................................................. 9 6.0 Utilization Management Functions .......................... 9 6.1 Prior Authorization .......................................... 10 6.2 Concurrent Review .......................................... 10 6.3 Discharge Planning .......................................... 10 6.4 Case Management ........................................... 11 6.5 Disease Management ....................................... 11 6.6 Out -of -Area Review ........................................ 11 6.7 Retrospective Review ........................................ 12 6.8 Ambulatory Review ......................................... 12 7.0 Delegation Guidelines ......................................... 12 8.0 Related Activities .............................................. 13 8.1 Updated UM Program Description ........................ 13 8.2 UM Program Evaluation .................................... 13 8.3 UM Work Plan ............................................... 14 8.4 Confidentiality Guidelines .................................. 14 Page 2 PACIFICARE OF COLORADO UTILIZATION MANAGEMENT PROGRAM DESCRIPTION 1998 9.0 Organizational Structure ...................................... 14 9.1 Board of Directors ........................................... 14 9.2 Quality Improvement Committee ......................... 15 93 Medical Management Committee ......................... 16 9.4 Delegation Committee ...................................... 17 9.5 Peer Review Committee .................................... 18 9.6 PHS Technology Assessment Committee ............... 19 9.7 Members Relations Committee ............................ 20 10.0 Roles and Responsibilities .................................... 20 10.1 Medical Director ............................................. 20 10.2 Directors of Medical Management ........................ 21 10.3 Medical Management Staff .............................. 22 10.4 Delegation Oversight ........................................ 22 11.0 Roles and Responsibilities: Delegated Provider Group.. 23 11.1 Medical Management Committee .......................... 23 12.0 Contracting Providers ......................................... 25 Appendices A. UM Program QI Committee Structure B. UM Departmental 1998 Utilization Management Goals Page 3 PACIFICARE OF COLORADO UTILIZATION MANAGEMENT PROGRAM DESCRIPTION 1998 1.0 Introduction PacifiCare of Colorado has developed a comprehensive Utilization Management (UM) Program that provides a framework for monitoring the use of services and evaluating the appropriateness of care resources. The organizational structure of the UM Program is illustrated in Appendix A. The UM Program Description is utilized to define the goals, scope, structure, function and other components of the UM Program at PacifiCare of Colorado. 2.0 Purpose The purpose of the UM Program is to foster access to appropriate, quality and cost effective care for members. Utilization Management involves the assessment, evaluation, planning, and implementation of health care services. At PacifiCare of Colorado, UM is integrated with PacifiCare's Quality Improvement (QI) Program, and Managed Behavioral Health Organization Services (MBHO), which promotes objective, systematic monitoring and evaluation of appropriate resources throughout the continuum of care. 3.0 Mission PacifiCare of Colorado's mission is to improve the health outcomes and satisfaction of its members through collaborative relationships with its contracting provider partners. This mission is accomplished through focusing on continuous quality improvement and leveraging best practices throughout the region. PacifiCare of Colorado supports its contracting provider partners through information analysis, education, development, operating systems and medical management expertise. PacifiCare of Colorado strives to maximize customer service through a competitive array of products supported by consistent systems and processes. PacifiCare of Colorado is dedicated to enhance employees' individual capacity and their contributions to the Plan by devoting resources to their ongoing development and education. 4.0 Goals and Objectives The PacifiCare of Colorado UM Program is designed to improve the quality of clinical care and quality of services provided to Plan customers. The goals of the Utilization Management Program include, but are not limited to: 4.1 Maintain a well functioning UM Program • Prioritize and implement UM initiatives and measure effectiveness • Maintain strong collaboration with the provider network • Maintain effective monitoring and oversight of delegated UM functions Page 4 PACIFICARE OF COLORADO UTILIZATION MANAGEMENT PROGRAM DESCRIPTION 1998 • Communicate results of findings, including recommendations for improvement, to the Medical Groups and Managed Behavioral Health Organization (MBHO) • Develop opportunities for licensed staff to achieve and/or maintain certification credentials • Conduct an Annual Utilization Management Program Evaluation in conjunction with the Annual QI Evaluation 4.2 Monitor systems which impact delivery of care • Analyze UM indicators against performance goals and recognized benchmarks • Seek to identify "best practices" utilized in care delivery throughout the provider network • Monitor compliance with UM criteria and practice guidelines 4.3 Evaluate systems that provide equitable access to care across the network • Promote member access to medical and behavioral health services at the most appropriate and least restrictive level of care • Monitor member access and provider availability to care • Promote timely and appropriate referral to care • Enhance processes that address both under- and over -utilization of services 4.4 Strengthen PacifiCare of Colorado's involvement on the PHS Technology Assessment Committee 4.5 Monitor the effectiveness of the member appeal process 4.6 Promote initiatives in both individual Case Management and population -based Disease Management Programs: • Enhance systems to identify at -risk populations for potentially preventable complications • Facilitate outreach activities associated with QI study initiatives 4.7 Evaluate customer perception of UM related functions and develop processes to improve as indicated 5.0 Program Scope and Content The scope of the UM Program is designed to objectively and systematically evaluate and improve the quality and appropriateness of care and service provided to members. Monitoring is designed to identify and pursue opportunities for improvement. Monitoring extends to both delegated and non -delegated functions. Page 5 PACIFICARE OF COLORADO UTILIZATION MANAGEMENT PROGRAM DESCRIPTION 1998 PacifiCare of Colorado arranges for the provision of medical care to members through a network of contracting primary care and specialty physicians, behavioral health clinicians, ancillary care providers, hospital and other facilities. Care is comprehensive, providing for conditions both acute and chronic in nature. The scope extends to Commercial and Secure Horizons (individual and group retiree) members. MBHO services include assessment, triage, referral and provision of medically necessary care of mental disorders as well as chemical dependency. All care services are offered in the context of the member's defined benefit plan. 5.1 Monitoring and Evaluation The UM Program's scope includes, but is not limited to, monitoring and evaluation of the following: • Services provided in inpatient hospitals, home care, skilled nursing facilities, residential treatment facilities, subacute facilities and other treatment centers • Appropriateness and medical necessity of pre -authorization decisions • Timeliness of the authorization process • Completeness of denial decisions • Adequacy of member communications regarding denial decisions • Consistency of UM decisions in prior authorization and in concurrent review • Adequacy of discharge plan and follow-up services • Appropriateness of Case Management referrals • Identification of QI referrals • Consistency of ER decisions • Satisfaction with UM related processes • Physician and member appeals • Utilization trends including under- and over -utilization (Individual case under - utilization reviewed by Peer Review Committee) 5.2 Data Sources Data is systematically collected and organized so that those responsible for monitoring the UM functions can determine when future evaluation is required. PacifiCare utilizes numerous data sources in the development, monitoring and evaluation of the UM Program. These include, but are not limited to, the following: • MBHO Reports • Provider Precontractual Assessment • Provider/Member Focus Groups • Intercompany Statistics • Demographic Analysis Page 6 PACIFICARE OF COLORADO UTILIZATION MANAGEMENT PROGRAM DESCRIPTION 1998 • Delegated Medical Group Authorization Logs • Denial Reports • Concurrent Review Reports • Readmission Reports • Case Management Reports • Days per Thousand Reports • Provider Data Report Set • QI Referral Reports • Access Audit Reports • Appeal and Grievance Statistics • Home Health Reports • Provider and Member Surveys • Medical Record Reviews • Pharmacy Reports • Delegated UM Reports The summary of information obtained from many of these sources results in a Provider Profile. These profiles are then utilized to monitor a wide array of performance indicators including those to detect under and over -utilization. 5.3 Indicators The UM Program's monitoring and evaluation methods are based on the use of both clinical and service indicators. Indicators are determined through an analysis of data including demographic, utilization and service analysis. Indicators are reported to the appropriate committee within the QI structure. Utilization related indicators are categorized in several ways: physician access, inpatient care, ambulatory care, behavioral health, appeals, and quality. Indicators are evaluated on an annual basis for inclusion and exclusion. Specific utilization indicators focus on the following areas: • Inpatient Days Per Thousand (Medical/Surgical, Mental Health) • Inpatient Admit Rates • Average Length of Stay • Outpatient Mental Health • Outpatient Alcohol/Drug • Skilled Nursing Days Per Thousand • Home Health • Readmissions • HEDIS Indicators • Timeliness of Authorization Page 7 G. Financial 1. The City currently uses the 1997-98 St. Anthony's RVS Schedule for Physicians for the network services. Will you agree to continue the use of these schedules? If no, please indicate the schedules you currently use. Do your factors vary by area throughout your network? Please specify. For 1998, PacifiCare has developed a fee schedule that is based primarily upon McGraw-Hill. Because of the very extensive database that has been compiled by our organization over the years, we have made modifications to McGraw-Hill for those CPT codes that we believe McGraw-Hill may be incorrect or has not established a value. We establish the unit value of these codes through a very refined process that is directed by a staff physician. The research put into review is extensive, and revisions receive approval by our Medical Management Department, Physician committees and PacifiCare Senior Management. There are a few individual fee schedules with terms that have been negotiated with some individual providers. For 1999, PacifiCare will be moving to the RBRVS schedule. The State of Colorado has only one schedule for all areas. H. Conversion Factors Please furnish conversion factors applicable to the 1997-98 St. Anthony's RVS Schedule for Physicians for determining your Participating Physician's maximum allowable charge for a covered service(s), as determined by the Plan. For purposes of your response to this request, please identify whether a withhold arrangement is assumed. -0 Proprietary information. Medicine $ Surgery $ Obstetrical $ Radiology $ Pathology (laboratory) $ Anesthesia $ For unlisted or by -report procedures, will you approve 80% of usual, customary and reasonable charges, as determined by the City, as the participating physician's maximum allowable charge? If not, please submit your proposal for the pricing of these claims. For unlisted or by -report procedures, all billed charges are reviewed by a registered nurse or a physician for appropriate unit values and reimbursement amounts. If an amount cannot be determined based on additional claims data or experience, 80% of billed charges will be approved. If lab fee reimbursements are not to be based on the 1997-98 St. Anthony's RVS Schedule for Physicians, please describe your proposed reimbursement arrangement. -0 Proprietary information 14 PACIFICARE OF COLORADO UTILIZATION MANAGEMENT PROGRAM DESCRIPTION 1998 5.4 Criteria PacifiCare of Colorado uses specific utilization criteria which includes InterQual, Medicare Guidelines, Western Region, PAS Length of Stay Guidelines, as well as internally developed criteria Criteria utilized for monitoring utilization are reviewed and updated annually by the Health Care Standards and Education Committee. Criteria are available upon request to contracting physicians. Medical Groups and MBHOs which have been delegated prior authorization are responsible for assessing the inter -reviewer reliability of decisions. PacifiCare of Colorado monitors and takes action to improve performance as part of the delegated oversight process. Behavioral health criteria are utilized to evaluate the necessity and appropriateness of mental health and chemical dependency services. Criteria is internally developed utilizing empirical research, industry -wide best practices, and expert professional experience. 5.5 Authorization Decisions All authorization decisions are supported by relevant clinical information appropriate to each case (such as medical records, consultation with the treating practitioner, etc.). Board certified physicians from appropriate specialty areas are utilized to assist in making determinations of medical necessity as indicated. All denial decisions related to medical necessity are reviewed by a licensed physician or licensed clinical psychologist. Decisions are made in a timely manner to accommodate the clinical urgency of the situation. These standards are developed by the PacifiCare of Colorado Utilization Management Department and included in policies and procedures adopted by the Plan. Medical Groups and MBHOs which have been delegated prior authorization are responsible for assessing timeliness of performance. PacifiCare of Colorado monitors and takes action to improve performance as part of the delegation oversight process. 5.6 Denial's/Appeals All prior authorization decisions are communicated in writing to both members and delegated Medical Groups or MBHOs. These letters contain the reason for the denial and information on the PacifiCare of Colorado, member and provider appeal process. Medical Groups and MBHOs which have been delegated prior Page 8 PACIFICARE OF COLORADO UTILIZATION MANAGEMENT PROGRAM DESCRIPTION 1998 authorization are responsible for ensuring an appropriate provider appeal process. PacifiCare of Colorado monitors and takes appropriate action to ensure compliance as part of the delegation oversight process. PacifiCare of Colorado maintains responsibility for the member appeal process. 5.7 Corrective Action/Follow-up Continuously monitored indicators related to Utilization Management are measured and trended over time to identify special causes of variation. On a routine basis, results are reported to the Medical Management Committee and QI Committee. The Committees are responsible for providing structured guidance and oversight. Recommendations for improvement in care and service are communicated to direct contracted physicians, non -delegated physician groups and MBHOs. When performance issues are identified, the Medical Management Committee may request the development and implementation of a corrective action plan. The focus of all corrective action will be educational and consultative rather than punitive in nature. PacifiCare may revoke delegation of activities if the Medical Group or MBHO is not performing in accordance with the standards, protocols, policies, and procedures established by PacifiCare or other regulatory or accreditation agencies. 5.8 Prioritization Certain aspects of clinical care and service may identify opportunities to maximize the use of quality improvement resources. Priority will be given to the following: • Those aspects of care which occur most frequently or affect large numbers of members • Those diagnoses in which members are at risk for serious consequences or deprivation of substantial benefit if care does not meet community standards or is not medically indicated • Those procedures involved in the delivery of care or service which, through process improvement, intervention could achieve a higher level of performance 6.0 Utilization Management Functions All Utilization Management functions are detailed in policies and procedures which are maintained in the Utilization Management Department. Policies and procedures are Page 9 PACIFICARE OF COLORADO UTILIZATION MANAGEMENT PROGRAM DESCRIPTION 1998 updated at least annually or more frequently as necessary through the Policy/Procedure Committee. Delegated entities are required to maintain policies and procedures that are consistent with PacifiCare of Colorado and update them annually. 6.1 Prior Authorization Prior authorization involves the assessment of the appropriateness of a proposed service. The basic elements of prior authorization review include: eligibility verification, benefit interpretation and medical necessity review for approval of both in and out patient services. Medical Groups and/or MBHOs responsible for prior authorization assess medical appropriateness following the same basic elements. 6.2 Concurrent Review Concurrent review is an assessment of ongoing medical and behavioral health services to determine continued medical necessity and appropriateness of care. This process is utilized for inpatient care, transitional care, home health, and those patients that qualify for ambulatory care management. Concurrent review is performed by clinical reviewers on site in the hospitals. The On -site Review Nurses are registered nurses who conduct these reviews under the direction of PacifiCare's Medical Director, in accordance with UM Policies and Procedures, utilizing InterQual Criteria and Medicare Guidelines. MBHO Case Managers conduct concurrent review. Appropriateness is determined by level of care, the intensity of services, and the severity of symptoms. Inter -reviewer reliability for consistency of UM decisions is conducted by the Medical Group, MBHO or PacifiCare depending on the responsibility for this function. UM cases that fall outside of the guidelines are discussed with the treating physician directly. Should further intervention be required, the situation is referred to PacifiCare's Medical Director or when UM is delegated, to the Medical Group's Medical Director. 6.3 Discharge Planning Discharge planning is coordination of a patient's continued care needs when discharged from the inpatient setting. The initial evaluation for discharge Page 10 PACIFICARE OF COLORADO UTILIZATION MANAGEMENT PROGRAM DESCRIPTION 1998 planning begins at the time of notification of inpatient admission. A comprehensive discharge plan includes assessment of needs, plan development, plan implementation and evaluation of effectiveness. 6.4 Case Management Case Management is a process for the management of chronic medical and behavioral health conditions which includes unexpected catastrophic occurrences, as well as proactive management of anticipated medical management situations. The case management process extends the discharge planning process for member/patients identified as needing coordination of a comprehensive or multifaceted medical case management program. The process is used for both inpatient and ambulatory care services. The Case Manager is a licensed registered nurse or master's level licensed behavioral health clinician who works with the physician to assist in facilitating the delivery of quality health care services in the most appropriate and least restrictive manner. 6.5 Disease Management The development and implementation of disease state management programs to proactively impact the quality of care to members is an integral aspect of care management. Programs are developed primarily as a result of evaluating Plan population demographics and epidemiological data as well as QI study findings. Disease management programs are coordinated and tracked through Case Management. Outcomes of the programs are reported to the Medical Management Committee and the QI Committee. 6.6 Out -of -Area Review PacifiCare or MBHO clinical staff monitors all out -of -area patients by phone and follows the same guidelines as for on -site concurrent review and discharge planning. All situations requiring physician review or intervention are referred to the Primary Care Physician, PacifiCare Medical Director or physician designee. When appropriate, members are transferred to in -network facilities for continued care by the Primary Care Physician or MBHO clinical staff. Page 11 PACIFICARE OF COLORADO UTILIZATION MANAGEMENT PROGRAM DESCRIPTION 1998 6.7 Retrospective Review Retrospective review is conducted by PacifiCare, the delegated Medical Group. or MBHO clinical staff based on established review guidelines. The process includes reviewing medical or behavioral health care treatments after the service has been provided, components of eligibility determination, medical necessity, level of care, appropriateness and administrative issues such as physician or MBHO notification, emergency status of admission and other criteria as appropriate. Quality monitoring is also performed. 6.8 Ambulatory Review Review of ambulatory services is conducted by PacifiCare, the delegated Medical Group, or MBHO clinical staff based on established review guidelines or as requested by a provider or member. Ambulatory care includes but is not limited to outpatient diagnostic, surgical, home health, DME and infusion service, etc. The overall goal of ambulatory review is to facilitate the organization and sequencing of appropriate health care services enhancing quality of care, and promoting optimal outcomes for all parties involved. Ambulatory review includes assessing all medical or behavioral health treatments provided in the home or other ambulatory setting for medical necessity and appropriateness. Ancillary providers work collaboratively to create outcomes based treatment plans and provide supporting utilization data reports. All situations requiring physician review or intervention are referred to the physician providing care, MBHO, PacifiCare Medical Director or physician designee. Compensation plans for individuals who provide utilization review services do not contain incentives, direct or indirect, for these individuals to make inappropriate review decisions. 7.0 Delegation Guidelines PacifiCare of Colorado may delegate Utilization Management to entities who meet PacifiCare standards for delegation. PacifiCare of Colorado does delegate certain components of Utilization Management to Medical Groups and Managed Behavioral Health Organizations. Precertification/Referrals, Benefit Administration, catastrophic case management, concurrent review and retrospective review may be delegated. All delegation activities are based on a pre -delegation assessment and ongoing annual monitoring and oversight to ensure that the entity meets PacifiCare's policies, procedures Page 12 PACIFICARE OF COLORADO UTILIZATION MANAGEMENT PROGRAM DESCRIPTION 1998 and goals of continuous quality improvement. The Delegation Committee is accountable for approval of delegated activities. A contract that specifies the terms and conditions of the delegation is signed by both parties. PacifiCare retains accountability for the functions delegated and performs oversight of these activities through the Delegation Committee, the Quality Improvement Committee and the Medical Management Committee in the following manner: • Analysis of monthly and/or quarterly reports required from the Medical Groups/MBHOs • Annual evaluation of delegated functions • Evaluation of member and practitioner satisfaction surveys • Analysis of monthly information from PacifiCare of Colorado complaint and quality of care databases 8.0 Related Activities 8.1 Updating of the UM Program Description The PacifiCare of Colorado Utilization Management Program will be revised and updated annually. A Work Plan is established annually in conjunction with the evaluation of the UM Program and revision to the UM Program Description. Revisions of the Program Description, Annual Work Plan and Evaluation will be approved through and presented to the Medical Management Committee and QI Committee. 8.2 UM Program Evaluation The UM Program Evaluation is incorporated into the Annual QI Program Evaluation and is presented to the QI Committee annually. The Director of Quality Improvement will coordinate the evaluation. The evaluation will be a written description of how PacifiCare of Colorado implemented and met the objectives of the UM Program. The UM evaluation is also forwarded to the Board of Directors for review as part of the Annual QI Evaluation. The UM Program Evaluation, which is conducted on the prior year's activity, includes, but is not limited to, the following components: • Review and evaluation of the UM Program structure and functions • Assessment of completed and ongoing UM activities • Trending of measures to assess performance of continuous monitors and indicators Page 13 PACIFICARE OF COLORADO UTILIZATION MANAGEMENT PROGRAM DESCRIPTION 1998 • Recommendation of program objectives and direction for the succeeding year • Review of criteria used to determine appropriateness • Evaluation of the overall impact of the UM Program on members and contracting providers • Identification of components of the program which need to be expanded, revised or deleted 8.3 UM Work Plan The UM Program Evaluation provides the starting point for development of the succeeding year's annual UM Work Plan. The purpose of the UM Work Plan is to implement a systematic method of tracking areas identified for improvement to assure appropriate and timely action was taken demonstrating plan -wide sustained improvement in quality of care and service. The 1998 Work Plan can be found in Appendix B. 8.4 Confidentiality Guidelines All employees and agents of PacifiCare and the employees and agents of all contracting practitioners will maintain the confidentiality of member information, medical records, peer review and quality improvement records and will assure that such information and records are not, whether inadvertently or purposefully, improperly disclosed, lost, altered, tampered with, destroyed or misused in any manner. No reviewer shall review a case in which he/she has been the attending physician or consulting physician, in which a partner in a medical practice has been the attending physician or when a close family relative is involved. Release of information will be in accordance with State and Federal laws. See QI Program Description for confidentiality guidelines related to Committee activity with the QI structure. 9.0 Organizational Structure Oversight of the Utilization Management Program is provided through a committee network which allows for a flow of information to and from the Quality Improvement Committee and Board of Directors. See Appendix A for organizational structure chart. 9.1 Board of Directors (BoD) 9.1.1 Policy Statement Ultimate accountability for PacifiCare of Colorado's QI Program rests with the market's Board of Directors. The Board demonstrates Page 14 PACIFICARE OF COLORADO UTILIZATION MANAGEMENT PROGRAM DESCRIPTION 1998 meaningful oversight and involvement in the Plan's QI Program. The Board formally delegated the day-to-day operational activities to the Quality Improvement Committee and the Medical Director. 9.1.2 Functions and Responsibilities Functions of the PacifiCare of Colorado Board of Directors include, but are not limited to, the following: • Annual review and approval of the QI Program Description, QI Work Plan and QI Program Evaluation • Designation of the Market Quality Improvement Committee to design and implement the QI Program • Review of reports on the status of the QI Program at each of the Board's regularly scheduled meetings • Designation of the Credentialing Committee as the body responsible for reviewing credentialing, re-credentialing data and making decisions regarding approval or denial of practitioners for participation in the Plan. • Evaluate effectiveness of Quality Improvement activities and providing feedback or direction as appropriate. • Provide oversight of financial performance of the health plan. • Establish direction and strategy for the health plan and evaluate its performance with corporate goals. • Designation of the Delegation Committee as the body responsible for determining delegation status. 9.2 Quality Improvement Committee 9.2.1. Policy Statement The PacifiCare of Colorado Quality Improvement Committee retains the operational accountability for the design and implementation of the QI Program. It oversees the quality of service operations and clinical care provided to PacifiCare of Colorado members. 9.2.2 Functions and Responsibilities Functions of the QIC include, but are not limited to, the following: • Report Quality Improvement activities to market Board of Directors and secondarily to the PHS National QI Committee. • Monitor performance and review reports from the Medical or Quality Improvement Directors, or PHS Health Services. Page 15 PACIFICARE OF COLORADO UTILIZATION MANAGEMENT PROGRAM DESCRIPTION 1998 • Ensure implementation and monitor performance on key quality of care and service indicators. • Review established quality of care and service indicators regularly. • Adopt clinical practice and prevention health guidelines. • Receive and review reports from other committees, including the Credentialing Committee, Service Solutions Committee, Peer Review Committee, Delegation Committee, Quality Improvement Projects Committee and Medical Management Committee. • Commission focused audits and quality improvement studies. • Recommend interventions for quality improvement. • Identify and develop strategies to reduce adverse outcomes. • Ensure and oversee the development and implementation of the QI/UM Program Description, Work Plan and Annual QI/UM Program Evaluation. • Develop and present comprehensive quarterly reports and the Annual QI Evaluation to the Board for it's approval, comment and recommendations. • Review and approve market policies, as applicable to Quality Improvement. • Assess effectiveness and efficiency of Quality Improvement resource allocation and management. • Assess over/under utilization. • Review and approve clinical care management programs in collaboration with other departments. • Review and analyze trends for opportunities for improvement for member services. 9.2.4 Reporting Relationships The QIC reports to the Board of Directors on a quarterly basis. The Chairperson of the QIC will present the reports to the BoD. 9.3 Medical Management Committee 9.3.1 Policy Statement The PacifiCare of Colorado Medical Management Committee reviews Utilization Management activities, technology assessment activities and practice patterns for direct contract providers and for those providers for whom PacifiCare performs Utilization Management functions. 9.3.2 Functions and Responsibilities Page 16 PACIFICARE OF COLORADO UTILIZATION MANAGEMENT PROGRAM DESCRIPTION 1998 The functions of the Medical Management Committee include, but are not limited to, the following: • Review and approve UM Program Description and Annual UM Program Evaluation of the program as delegated by the QIC. • Analyze trends and develop medical management cost containment programs. • Review and approve UM criteria for assessing medical necessity of care. • Review and approve UM standards and communication to providers, members and staff. • Evaluate non -delegated participating physician practice patterns, provide feedback, and review/approve corrective action plans, as needed. • Assess effectiveness and efficiency of resource allocation and management. • Review and approve UM policies/procedures. • Assess over- and under -utilization. • Review trends and develop strategies to reduce adverse outcomes. • Review, approve, and report quality of care service indicators for UM. • Review and approve Technology Assessment procedures including new applications of existing technologies. (Report will originate from Health Care Standards and Education Committee) • Review and approve clinical care management programs in collaboration with other departments. • Review and approve communication of standards, policies and procedures, and guidelines to providers, members and staff. • Review and approve medical policies in relation to coverage or payment of services. • Review and approve quarterly reports to the QIC. 9.3.4 Reporting Relationships The Medical Management Committee reports to the QI Committee quarterly. 9.4 Delegation Committee 9.4.1 Policy Statement The PacifiCare of Colorado Delegation Committee is responsible for the oversight of all delegated activities of service activities. Page 17 Hospital What is the average discount over allowable for Metro Denver area hospitals in aggregate at a minimum, by hospital preferred? -0 Proprietary information 2. Please complete the following table for McKee Medical Center, Poudre Valley Hospital and North Colorado Medical Center facilities, as applicable. -:> Proprietary information Name of Hospital: Indicate type and amount of contractual a reements (per diem or DRG referred): Negotiated Rates: Invatient: Medical/Surgical ICU/CCU Normal Vaginal Delivery C-Section NICU Other (specify) Ou atient: Other (specify) 15 PACIFICARE OF COLORADO UTILIZATION MANAGEMENT PROGRAM DESCRIPTION 1998 9.4.2 Functions and Responsibilities Performance responsibilities include, but are not limited to the following: • Review and approve delegated policies and procedures including workflows. • Review and approve provider/practitioner criteria for network participation. • Prioritize delegated service initiatives focusing on customer service improvements. • Review and analyze current and past delegated service initiatives or changes in process to determine effectiveness and future opportunities for improvement. • Provide oversight to provider delegated activities. • Provide reports to Medical Management on matters of provider network performance. • Report to the QIC regarding delegation decisions. • Approve all delegation status. • Review, approve and report corrected action plans to QIC. 9.4.3 Reporting Relationships The Delegation Committee should report to the QIC on at least a bi- monthly basis. 9.5 Peer Review Committee 9.5.1 Policy Statement The PacifiCare of Colorado Peer Review Committee (PRC) consists of contracted physicians who represent the provider network, regional Quality Improvement Program staff, and regional Provider Relations representatives. Each PRC has a physician chairperson PacifiCare Medical Director appointed by the Quality Improvement Committee. Each PRC is responsible for the operational implementation of the QI Program and Work Plan within their respective market or geographic area as it relates to Peer Review. 9.5.2 Functions and Responsibilities The functions of the Peer Review Committee include, but are not limited to, the following: Identify quality of clinical care issues through the review of medical charts and Quality Improvement data. Page 18 PACIFICARE OF COLORADO UTILIZATION MANAGEMENT PROGRAM DESCRIPTION 1998 • Review and evaluate Quality Improvement findings. • Report Quality Improvement activities to the Quality Improvement Committee and establish corrective action plans as needed. • Provide input to policy and procedure development related to benefit issues, and technology assessment requirements. • Educate the provider network regarding Quality Improvement activities. • Make recommendations for development and approval of Clinical Practice Guidelines and Preventative Health Guidelines to the QIC. • Serve as link between the QIC and the field-based/market clinical staff. • Operationalize implementation of the QI Program and Work Plan within the market as it relates to Peer Review Committee. 9.5.3 Reporting Relationships The Peer Review Committee reports to the QIC on a biannual basis. 9.6 PHS Technology Assessment Committee (TAC) 9.6.1 Policy Statement The TAC is a corporate -wide committee that evaluates new or changed technologies relating to procedures, drugs, devices, diseases, and preventative services. The committee develops recommendations to assist benefit coverage determinations. The TAC supports a rational approach to the use of technology to improve the health care of PacifiCare of Colorado members. PacifiCare of Colorado is committed to providing appropriate, quality services to it's members. 9.6.2 Functions and Responsibilities The functions of the TAC include, but are not limited, to the following: • Prepare recommendations regarding new technology and recommend improving existing technologies. • Determine the status of technologies, e.g., experimental, investigational, accepted for clinical use. • Evaluate pharmacoeconomic studies and effectiveness data for drug therapies and other interventions. • Analyze outcome data as it relates to short- and long-term effectiveness, efficacy and safety. • Recommend guidelines by which the foregoing activities are conducted by the Plan. Page 19 PACIFICARE OF COLORADO UTILIZATION MANAGEMENT PROGRAM DESCRIPTION 1998 • Reduce variability in decision making and improve risk management. • Provide an educational vehicle for Plan and network providers. • Incorporate feedback to continuously reassess appropriateness of technology. 9.6.3 Reporting Relationships Corporate resource to PHS plans. 9.7 Members Relations Committee 9.7.1 Policy Statement The PacifiCare of Colorado Appeals and Grievances Committee is responsible for providing oversight to the appeals and grievance process that operates between the Regional Customer Service Center and the health market. 9.7.2 Functions and Responsibilities • Support the analysis of any appeal, convene second level hearings, and otherwise, facilitate the completion of any appeal. • Prepare a written response to the member. • Review and analyze appeals and grievances trends (plan -wide and by individual provider groups) on a quarterly basis. • Monitor timeframes to assure that the appeals and grievances process meets Plan standards. • Assure consistency in the interpretation and processing of appeals and grievances. • Identify barriers and opportunities for improvement. 9.7.3 Reporting Relationships The committee should report to the Service Solutions Committee on at least a bi-monthly basis. 10.0 Roles and Responsibilities 10.1 PacifiCare of Colorado Medical Director The PacifiCare of Colorado Vice President of Medical Management and Quality Improvement / Medical Director is accountable for providing leadership within the QI Program. The Director of Quality Improvement, Director of Utilization Management, Director of Pharmacy, Director of Operations, and SubMarket Medical Directors report directly to the PacifiCare of Colorado VP of Medical Page 20 PACIFICARE OF COLORADO UTILIZATION MANAGEMENT PROGRAM DESCRIPTION 1998 Management and QI / Medical Director. Performance accountabilities for the VP of Medical Management and QI / Medical Director and SubMarket Medical Directors include, but are not limited to, the following: • Monitor the implementation of the QI process as it relates to quality of care and assure that corrective actions are taken when problems are identified. • Participate in the development and design of the QI Program. • Participate in the Annual QI Program Evaluation. • Evaluate Plan studies and assist in the development of corrective action plans. • Monitor implementation of the QI, UM, and Credentialing programs in cooperation with committee chairs. • Chairperson of the Medical Management Committee. Chairs the QIC. Recommends chairs of Peer Review, Credentialing, Quality Improvement Projects Committee, Service Solutions Committee, Member Relations Committee. • Member of Senior Executive Management Committee, Quality Improvement Committee, Medical Management, Quality Improvement Projects Committee, Member Relations Committee. • Coordinate with contracted Provider Group Medical Directors in QI, UM, Health Education/Wellness, as applicable. • Coordinate and communicate peer review information and decisions to network physicians. • Participate in development of the QI Program, QI Work Plan, UM Program and Credentialing program. • Perform individual clinical case review (including grievances and appeals) and make corrective action recommendations on quality of care issues. • Review medical necessity denials. • Oversee UM inter -reviewer reliability process. • Evaluate clinical studies and assist in development of corrective action plans. • Analyze UM data and establish priorities for focused studies (high volume, high risk and high cost areas) in cooperation with the Medical Management Committee. • Contribute to development, review and dissemination of clinical studies and practice guidelines/standards to participating providers. • Review of all clinical indicators for ambulatory and inpatient care. 10.2 Directors of Utilization Management (UM) The Directors of Utilization Management oversee all Utilization Management functions. Clinical UM and related QI activities are performed under the guidance of the Directors of Utilization Management. Registered nurses, referral and precertification representatives, and support staff report to the Director of Page 21 PACIFICARE OF COLORADO UTILIZATION MANAGEMENT PROGRAM DESCRIPTION 1998 Utilization Management. Performance accountabilities for this position include, but are not limited to: • Facilitate strategic planning and direction consistent with corporate, regional, and marker initiatives • Promote consistency and standardization of processes related to Utilization Management • Facilitate monitoring for under- and over -utilization • Review aggregated clinical care and service indicators and trended reports focusing on variance analysis • Identify opportunities to improve Medical Group and PacifiCare of Colorado service • Monitor delegated UM activities • Facilitate review of policies and procedures and revision as necessary • Implement corrective action for performance improvement • Review and analyze member, provider and employer group satisfaction surveys, present findings and identify opportunities for improvement 10.3 Utilization Management Staff The UM staff is comprised or referral/precertification representatives, census coordinators, registered professional nurses, and physicians. The professional staff generally have a minimum of three to five years of clinical and utilization experience. Nurses are supervised by Managers, Directors and Medical Directors. Clerical staff support all functions. Consultants are available as needed. Orientation is provided for all staff. On an ongoing basis, staff participate in inservice education and are encouraged to attend external education conferences to maintain their competency. 10.4 Delegation Oversight The Project Manager for Delegation of Utilization Management coordinates the oversight of the delegated medical groups statewide. The Project Manager routinely meets with the registered professional nurses assigned to the delegated medical groups in each market. The following responsibilities are reviewed to assure consistency in performing the oversight function: • Oversight of medical groups' performance in: • Referral management • Prior authorization Page 22 PACIFICARE OF COLORADO UTILIZATION MANAGEMENT PROGRAM DESCRIPTION 1998 • Benefits management and treatment alternatives • Concurrent review • Annual and quarterly UM delegation audits • Interpretation of the delegated provider groups' contracts • Education of medical groups regarding • DOI regulations • HCFA regulations • NCQA standards The Project Manager for delegation is also responsible for: developing policies / procedures and workflows for delegation oversight activities, as well as coordinating with the Claims Department and the Provider Contracting Department to provide a global understanding of the medical groups business capabilities. 11.0 Roles and Responsibilities: Delegated Provider Group 11.1 Medical Management Committee Medical Group/IPA must have a Medical Management Committee (MMC). PacifiCare of Colorado recommends the MMC should be comprised of a Utilization Management Chairperson (Medical Director) and a minimum of three to five participating physicians, including both primary care and specialty physicians. PacifiCare of Colorado recommends the UMC should also include the Utilization Management Nurse and the Health Plan Coordinator. PacifiCare of Colorado recommends that physician members rotate through the Medical Management Committee in overlapping six month terms to provide consistent ongoing physician training and experience in the Utilization Management process. PacifiCare also recommends that newly contracted primary care physicians participate in at least 34 Medical Management Committee meetings as part of the Medical Group/IPA's orientation process. Only licensed and credentialed MD members of the Medical Group/IPA may be considered voting members of the MMC for the purpose of decision making. The Medical Management Committee should meet as frequently as necessary but not less than monthly. The primary role of the Medical Management Committee is to ensure appropriate utilization and medical necessity of services in the most cost effective setting. Their function may include: Page 23 PACIFICARE OF COLORADO UTILIZATION MANAGEMENT PROGRAM DESCRIPTION 1998 • Development, approval, and annual review of the Utilization Management Program. • Development, approval, and annual review of the Utilization Management policies and procedures and medical criteria used in the evaluation of appropriate health care services. • Development, approval, and annual review of the Utilization Management Program. • Discussion of current in -patient activity, patient status, and possible intervention with the admitting physician regarding discharge planning. • Monitoring quality of care and risk management issues and forwarding information to the appropriate committee for follow-up. • Implementing appropriate procedural guidelines for transferring members from out -of -network/out-of-area to in-network/in-area. • Ongoing assessment/review of Medical Group/IPA's compliance with authorization timelines (emergent, urgent, elective). Recommending/implementing processes to ensure compliance. • Oversight of the issuance of appropriate denial and level of care letters for patients who no longer require their current level of care. • Active review of utilization data and referral patterns as monitored by the health plan and the Medical Group/IPA Utilization Management Department. Makes appropriate clinical and operational changes to reduce utilization and maximize cost effectiveness. • Physician education regarding new technologies, medical guidelines, and UM policies and procedures. • Annual review of the effectiveness of the Medical Group/IPA Utilization Management Program, using member satisfaction data, provider satisfaction data and/or other appropriate means. • Identifying contracting needs to support appropriate utilization management strategies. • Monitoring and analyzing trends in utilization data and implementing appropriate utilization management strategies. • Disseminating pertinent utilization management information to the providers and appropriate staff within the Medical Group/IPA to maximize clinical and operational efficiencies. • Developing utilization performance benchmarks. • To meet NCQA or other accrediting agency standards and State and Federal Regulatory reporting requirements, PacifiCare and the Medical Group/IPA shall work together to incorporate systems to identify, track, and take action on under/over utilization, and quality and risk management issues. Page 24 PACIFICARE OF COLORADO UTILIZATION MANAGEMENT PROGRAM DESCRIPTION 1998 12.0 Contracting Providers PacifiCare interfaces daily with the Medical Group and Behavioral Health providers in various ways. Provider and facilities undergo a credentialing and recredentialing process which is consistent with PacifiCare and NCQA standards. Contracting network providers are required to have 24-hour coverage to insure timely and efficient member access. The MBHO has a toll -free telephone number for promptly accessing MBHO case managers on a 24-hour basis. The requirement is addressed in the contractual agreement and is monitored by the Provider Services Department and the Research and Planning Department. The monitoring results are reported to Committees within the QI structure. PacifiCare provides a comprehensive health care delivery system for its members including ambulatory care services, inpatient and outpatient hospital services and ancillary services. PacifiCare of Colorado is contracted with 42 hospitals, 1,184 primary care physicians and 2,522 specialists. Page 25 No Text PacifiCare of Colorado Quality Improvement Program Description 1998 QI Committee Approval: Medical Director Signature Approval Date: 4-23-98 Board of Directors Approval: Chairman Signature Approval Date• TPA SERVICES FEE QUOTATIONS Please provide your fee quotation with regard to the administrative services described in this section. Your fee quotation should be presented in the following format. -:� N/A PPO Plans OW Month, Charges Per - • le" With Run -In Medical Claims Administration Additional Charges: COBRA Administration Retiree Administration HIPAA Administration ID Cards Start -Up Fees Other (detail) $ $ $ per election/notice $ $ $ $ For purposes of your quote, please assume 605 eligibles in the PPO plans. z With Run -In POS EPO Medical Claims Administration $ $ $ $ Rx Administration Additional Charges: COBRA Administration $ per $ per election/notice election/notice Retiree Administration $ $ $ $ HIPAA Administration $ $ ID Cards $ $ Start -Up Fees $ $ Other (detail) For purposes of your quote, please assume 80 eligibles in the POS plan and 585 in the EPO plan. How do the above charges differ assuming you are selected to administer all plans? Note: (1) The costs of postage, telephone service, and printing of forms are assumed to be included in your fees. If not, please so note. (2) Charges for all required reports are to be included in the monthly fees. (3) Booklets and certificate preparation and distribution must be included in your fees. (4) Indicate any charges for customized identification cards. $ /card (5) Indicate if Retiree Administration (sending election notice, etc.) is separate charge. 16 PACIFICARE OF COLORADO QUALITY IMPROVEMENT PROGRAM DESCRIPTION 1998 Previous QI Program Approval Dates: Apri123, 1998, approved QI Committee (insert date), approved Board of Directors (insert date), approved QI Committee (insert date), approved Board of Directors Page 2 Revision dates: 1993, 4-18-94, 3-10-93, 10-27-94, 1-19-95, 1-15-96, 3-27-97, 4-23-98 1AQIPR0GRAMQ1PR0-9843098 1998 05/26/98 9:06 AM PACIFICARE OF COLORADO QUALITY IMPROVEMENT PROGRAM DESCRIPTION 1998 Table of Contents Section Paee No. 1.0 Introduction............................................................................5 2.0 Definition of Quality..............................................................5 3.0 Mission...................................................................................5 4.0 Purpose of the Quality Improvement Program ......................6 5.0 QI Strategy.............................................................................6 6.0 Goals and Objectives.............................................................6 7.0 Program Scope and Content...................................................8 7.1 Monitoring and Evaluation....................................................9 7.2 Data Sources..........................................................................9 7.3 Indicators................................................................................10 7.4 Studies....................................................................................10 7.5 Process................................................................................... I I 7.6 Prioritization..........................................................................11 8.0 Organizational Structure........................................................11 8.1 Board of Directors (BoD)......................................................11 8.2 Senior Executive Management Committee (SEMC).............13 8.3 Quality Improvement Committee(QIC)................................14 8.4 Credentialing Committee.......................................................16 8.5 Quality Improvement Projects Committee (QIPC)................17 8.6 Peer Review Committee........................................................18 8.7 Medical Management Committee ......................................... 20 8.8 Delegation Committee........................................................... 21 8.9 Service Solutions Committee(SSC)..................................... 22 8.10 Member Relations Committee ........................................... 23 9.0 Committee Guidelines...........................................................24 9.1 Meeting Minute Format.........................................................24 9.2 Meeting Minute Content........................................................25 9.3 Voting/Quorums....................................................................25 9.4 Membership Selection/Attendance........................................25 10.0 Roles/Responsibilities............................................................25 10.1 Regional Vice President.........................................................25 10.2 President of PacifiCare of Colorado......................................26 10.3 PacifiCare of Colorado Medical Director..............................26 10.4 Director of Quality Improvement..........................................27 10.5 Directors of Health Services..................................................29 Page 3 Revision dates: 1993, 4-28-94, 3-10-93, 10-27-94, 1-19-95, 1-15-96, 3-17-97, 4-13-98 1:\QEPR0GRAM\QIPR0-98-43098 1998 05/26/98 9:06 AM PACIFICARE OF COLORADO QUALITY IMPROVEMENT PROGRAM DESCRIPTION 1998 Table of Contents (continued) Section Page No. 10.6 Contracted Practitioners/Providers........................................ 29 10.7 PacifiCare Health Systems Corporate....................................30 Quality Improvement 11.0 Delegation..............................................................................30 12.0 Confidentiality.......................................................................32 12.1 Policy Statement....................................................................32 12.2 QI Committee Members........................................................32 12.3 Access to Information............................................................32 12.4 Meeting Materials/Minutes....................................................33 13.0 Risk Management..................................................................33 14.0 Annual Update of Program Description.................................33 15.0 Annual QI Program Evaluation.............................................33 16.0 Annual QI Work Plan ............................................................33 17.0 QI Program Integration..........................................................33 18.0 Disclosure..............................................................................34 Appendices A. Organizational Structure B. QI Work Plan C. Clinical and Service Indicators D. QI Committee Grid E. Definition of Terms (PHS glossary.) Page 4 Revision dates: 1993,4-28-94. 3-10-93, 10-27-94, 1-19-95, 1-15-96, 3-17-97, 4-23-98 C\Q1PR0GRAM\QIPR0-98-43098 1998 05/26/98 9:06 AM PACIFICARE OF COLORADO QUALITY IMPROVEMENT PROGRAM DESCRIPTION 1998 1.0 Introduction PacifiCare of Colorado has developed a comprehensive Quality Improvement (QI) Program that provides a framework for continuous assessment and improvement of all aspects of health care delivery and service. The organization structure of the QI Program is illustrated in Appendix A. The QI Program Description is utilized to define the goals, scope, structure, function and other components of the QI Program at PacifiCare of Colorado. A definition of terms is provided in Appendix E. 2.0 Definition of Quality PacifiCare of Colorado defines quality as conformance to measurable standards which may be defined by Plan sponsors, members, state regulators, providers, practitioners and external accreditation entities and which include professionally recognized standards of practice. 3.0 Mission PacifiCare of Colorado's mission is to improve the health outcomes and satisfaction of its members through collaborative relationships with its contracting provider partners. This mission is accomplished through focusing on continuous quality improvement and leveraging best practices throughout the region. PacifiCare of Colorado supports its contracting provider partners through information analysis, education, development, operating systems and medical management expertise. PacifiCare of Colorado strives to maximize customer service through a competitive array of products supported by consistent systems and processes. PacifiCare of Colorado is dedicated to enhance employees' individual capacity and their contributions to the region by devoting resources to their ongoing development and education in quality improvement. PacifiCare's aim is "Together we make lives better". Its vision is to be an organization of dedicated people committed to improving the quality of those lives we touch. The aim and vision are supported by the values of Integrity, People, Customer Service Quality, Accountability, Continuous Improvement, Teamwork and Empowerment. Page 5 Revision dates: 1993, 4-28-94, 3-10-93, 10-27-94, 1-19-95, 1-25-96, 3-27-97, 4-23-98 1 AQIPROGRAMIQIPR0-98-43098 1998 05/26/98 9:06 AM PACIFICARE OF COLORADO QUALITY IMPROVEMENT PROGRAM DESCRIPTION 1998 The PacifiCare of Colorado QI Program reflects PacifiCare's aim, vision and values. It is designed to initiate, monitor and evaluate standards of health care practice and customer service on an ongoing basis. 4.0 Purpose of the Quality Improvement Program The purpose of the PacifiCare of Colorado QI Program is to provide a formal process to objectively and systematically monitor and evaluate the quality, appropriateness, efficiency and effectiveness of care and service utilizing a multidimensional approach. This approach enables the organization to focus on opportunities for improving operational processes as well as health outcomes and member and practitioner/provider satisfaction. The QI Program promotes the accountability of all Health Plan employees and affiliated health personnel for the quality of care and services they provide to Plan customers. 5.0 QI Strategy The PacifiCare Quality Improvement strategy includes, but is not limited to, the following: • Competitively advantaged delivery systems for PacifiCare and our provider partners • Member satisfaction at the point of delivery • Demonstrated improvement in clinical quality outcomes • Managed health care costs consistent with maximizing value for our customers 6.0 Goals and Objectives The PacifiCare of Colorado QI Program is designed to assist the Plan in improving the quality of clinical care and quality of services provided to Plan customers. To that end, the goals of the Program are: A. Maintain QI structure and processes that support continuous quality improvement • Measure, trend and analyze QI activities against performance goals and/or recognized benchmarks • Implement strong interventions to improve performance • Measure the effectiveness of improvement actions Page 6 Revision dates: 1993, 4-28-94, 3-10-93, 10-27-94, 1-19-95, 1-25-96, 3-27-97, 4-23-98 C\QEPR0GRAM\QIPR0-9843098 1998 05/26/98 9:06 AM PACIFICARE OF COLORADO QUALITY IMPROVEMENT PROGRAM DESCRIPTION 1998 • Evaluate the QI Program and QI Work Plan annually B. Ensure adequate availability and accessibility to care and service and facilitate continuous improvement. C. Measure member satisfaction and implement effective interventions to address areas of dissatisfaction through, but not limited to: • Analysis of trended member complaint data • Quantitative analysis of PCP changes • Analysis of member disenrollment and member satisfaction data • Solicitation of member suggestions to improve care and service on an ongoing basis D. Ensure full compliance with all Federal and Colorado regulatory requirements as well as National Committee for Quality Assurance (NCQA) standards for accreditation. E. Ensure effective credentialing and recredentialing processes that comply with PacifiCare standards (inclusive of NCQA, HCFA and Colorado regulatory standards). Develop mechanisms to measure and implement actions to improve under- and over- utilization and continuity and coordination of care. G. Implement Utilization Management (UM) decision protocols internally and at the provider level to ensure reviewer consistency and regulatory compliance. H. Provide oversight of delegated activities including UM, Credentialing and Medical Records. Ensure delegates maintain compliance with Federal and Colorado regulatory requirements and NCQA standards for accreditation. Ensure effective coordination of QI activities with all appropriate functional areas, including, but not limited to, Utilization Management, Risk Management, Member Complaints, Appeals and Grievances, Member Satisfaction, Health Improvement and Wellness, Provider Education, Network Management and Credentialing. Page 7 Revision dates: 1993, 4-28-94, 3-10-93, 10-17-94, 1-19-95, 1-25-96, 3-27-97, 4-23-98 I:\QEPROGRAM\QIPRO-9843098 1998 05/26/98 9:06 AM PACIFICARE OF COLORADO QUALITY IMPROVEMENT PROGRAM DESCRIPTION 1998 J. Incorporate public health goals from the state of Colorado into the PacifiCare of Colorado QI Program. 7.0 Program Scope and Content The scope of the QI Program is designed to objectively and systematically evaluate and improve the quality of care and appropriateness of care and service provided to members both internally and externally by the participating provider network. Monitoring is designed to identify and pursue opportunities for improvement. Monitoring activities include care and service that are delivered by contracting primary care practitioners, specialty practitioners and providers. Monitoring extends to both delegated and non -delegated functions. All departments within the Plan are involved in the Quality Improvement process. The PacifiCare of Colorado QI Program incorporates the review and evaluation of important aspects of the healthcare delivery system. The review and evaluation of these components shall be coordinated by the Plan QI Department in order to demonstrate that the process is cross -functional, multidisciplinary, integrated and effective in demonstrating improvements in the quality of clinical care and services provided. PacifiCare of Colorado arranges for the provision of comprehensive health care delivery through a network of primary care and specialty practitioners, mental health practitioners and clinicians, ancillary care providers, hospitals and other facilities. Care is comprehensive providing for conditions both acute and chronic in nature. Preventive services and early detection of illness screenings are conducted at appropriate intervals. The scope of the QI Program encompasses all product lines. Page 8 Revision dates:1993, 4-28-94, 3-10-93, 10-17-94, 1-19-95, 1-25-96, 3-17-97, 4-23-98 19Q1PR0GRAM\Q 1PRO-9843098 1998 05/26/98 9:06 AM PACIFICARE OF COLORADO QUALITY IMPROVEMENT PROGRAM DESCRIPTION 1998 7.1 Monitoring and Evaluation: The QI Program scope includes, but is not limited to, monitoring and evaluation of the following: • Services provided in inpatient settings including hospitals, skilled nursing facilitates, and subacute facilities, and other treatment centers • Services provided in outpatient settings including home health care and ambulatory surgery centers • Services provided by primary care, high -volume specialty care and behavioral health practitioners • Utilization trends including under and over utilization • Performance of case review of suspected instances of poor quality • Review of medical record documentation practices • Evaluation of member, patient and provider satisfaction • Compliance with clinical practice and preventive health guidelines and access and availability standards • Compliance with health plan administrative service standards • Continuity and coordination of care members receive • Acute and chronic care • Preventive health services • Credentialing/Recredentialing activities 7.2 Data Sources and Staff Resources: PacifiCare utilizes numerous data sources in the development, monitoring and evaluation of the QI Program. These sources include, but are not limited to, the following: • Encounter data • Claims data • Pharmacy data • Medical records • Utilization review data • Provider and member complaint data • Provider and member surveys • Appeals and grievance information • Statistical, epidemiological and demographic member information • Authorization data • Enrollment data • HEDIS data • PacifiCare Behavioral Health Inc. data Page 9 Revision dates: 1993, 4-28-94, 3-10-93, 10-27-94, 1-19-95, 1-25-96, 3-27-97, 4-23-98 1 AQ 1PROGRAM\QIPRG-9843098 1998 05/26/98 9:06 AM PACIFICARE OF COLORADO QUALITY IMPROVEMENT PROGRAM DESCRIPTION 1998 In addition to PacifiCare of Colorado's internal staff resources, Corporate staff resources are provided through PacifiCare Health Systems (PHS). The QI and analytical resources include, but are not limited to: • Quality Improvement • Quality Measurement and Reporting (QMR) • Health Improvement • Utilization Management 7.3 Indicators: Annual goals are established for each indicator. Once the data is analyzed, the Quality Improvement Committee (QIC) will decide on the appropriate action. Where possible, the Health Plan will follow HEDIS data definitions and methods to establish baseline and ongoing measures. Multi -disciplinary teams will be involved in the analysis of performance gaps and the development of action plans. Monitoring results for these indicators will be reported to the appropriate quality committees, the QIC and the Board of Directors on an annual basis and included in the Annual QI Program Evaluation. PacifiCare of Colorado's clinical and service indicators are listed in Appendix C. 7.4 Studies: The QI Program's scope includes implementation of QI initiatives or studies. These studies are activities selected by the PacifiCare of Colorado QI Committee that are designed to improve performance of selected high volume and/or high risk aspects of clinical care and member service. The following clinical and service issues are being studied for calendar year1998-1999: Clinical Preventive Health Service Acute Myocardial Infarction Childhood Immunizations PCP Changes Diabetes Management Adult Immunizations Member Satisfaction Congestive Heart Failure Management Cervical Cancer Screening Call Responsiveness Depression Breast Cancer Screening Access and Availability Check Up After Delivery Prenatal Care I' Trimester Appeals VBAC & C/Section Disenrollment Page 10 Revision dates: 1993, 4-28-94, 3-10-93, 10-27-94, 1-/9-95, 1-25-96, 3-17-97, 4-23-98 L\QIPROGRA WQIPRO-98-43098 1998 05/26/98 9:06 AM PACIFICARE OF COLORADO QUALITY IMPROVEMENT PROGRAM DESCRIPTION 1998 Referrals Member Complaint tracking 7.5 Process: Quality activities are conducted utilizing a systematic process: • Define specific indicators of performance • Collect appropriate data • Analyze data • Identify opportunities to improve performance • Implement interventions to improve performance • Implement guidelines when applicable • Measure effectiveness of interventions and/or conformance to guidelines • Re-evaluate for further performance improvements 7.6 Prioritization: Certain aspects of clinical care and service may identify opportunities to maximize the use of quality improvement resources. Priority will be given to the following: • Those aspects of care which occur most frequently or affect large numbers of members • Those diagnoses in which members are at risk for serious consequences or deprivation of substantial benefit if care does not meet community standards or is not medically indicated • Those processes involved in the delivery of care or service which, through process improvement intervention could achieve a higher level of performance. • The annual analysis of Plan specific demographic and epidemiological data. 8.0 Organizational Structure Oversight of the Quality Improvement Program is provided through a committee network which allows for the flow of information to and from the Board of Directors. An organizational chart is shown in Appendix A and a QI Committee grid can be found in Appendix D. Page 11 Revision dares: 1993, 4-28-94, 3-10-93, 10-27-94, 1-19-95, 1-25-96, 3-17-97, 4-23-98 1:\QIPR0GRAM\Q1PR0-98.43098 1998 05/26/98 9:06 AM TPA SERVICES FEE QUOTATIONS Please provide your fee quotation with regard to the administrative services described in this section. Your fee quotation should be presented in the following format. Monthly Charges PPO Plans Oniv , Per amble Without Run -In Medical Claims Administration Additional Charges: COBRA Administration Retiree Administration HIPAA Administration ID Cards Start -Up Fees Other (detail) $ 34.31* $ Not available per election/notice $ Not available $ Not available $ Included in admin fee above $ N/A $ N/A For purposes of your quote, please assume 605 eligibles in the PPO plans. 'J Sag Without Run -In POS EPO Medical Claims Administration $ 31.52* $ 31.27* Rx Administration $Included above $ Included above Additional Charges: COBRA Administration $ Not available $ Not available per election/notice per election/notice Retiree Administration $ Not available $ Not available HIPAA Administration $ Not available $ Not available ID Cards $ Included in $ Included in admire fee above admin fee above $ N/A Start -Up Fees $ N/A Other (detail) $ N/A $ N/A * Represents total fee composite for bundled services of UR, network access and TPA Services. All services provided unless specifically stated otherwise. Incentive risk charges are not included in the numbers shown above. For purposes of your quote, please assume 80 eligibles in the POS plan and 585 in the EPO plan. 17 PACIFICARE OF COLORADO QUALITY IMPROVEMENT PROGRAM DESCRIPTION 1998 8.1 Board of Directors (BoD) Policy Statement: Ultimate accountability for PacifiCare of Colorado's QI Program rests with the market's Board of Directors. The Board demonstrates meaningful oversight and involvement in the Plan's QI Program. The Board has formally delegated the day-to-day operational activities to the Quality Improvement Committee and the Medical Director. Responsibilities and Functions: Functions of the PacifiCare of Colorado Board of Directors include, but are not limited to, the following: • Annual review and approval of the QI program Description, QI Work Plan and QI Program Evaluation. • Designation of the Market Quality Improvement Committee to design and implement the QI Program. • Review of reports on the status of the QI Program at each of the Board's regularly scheduled meetings. • Designation of the Credentialing committee as the body responsible for reviewing credentialing and recredentialing data and making decisions regarding approval or denial of practitioners for participation in the Plan. • Evaluate effectiveness of Quality Improvement activities and providing feedback or direction as appropriate. • Provide oversight of financial performance of the health plan. • Establish direction and strategy for health plan and evaluate its performance with corporate goals. • Designation of the Delegation Committee as the body responsible for determining delegation status. Frequency of Meetings: The Board of Directors meets no less than quarterly. Composition of Board of Directors • Executive Vice President/Chief Operating Officer of Pacificare Health Systems (PHS) • PHS Executive Vice President, Chief Administrative Officer, Chief Financial Officer. Page 12 Revision dates: 1993, 4-28-94, 3-10-93, 10-27-94, 1-19-95, 1-25-96, 3-27-97, 4-23-98 CIQIPR0GRAM\QIPR0-98-43098 1998 05/26/98 9:06 AM PACIFICARE OF COLORADO QUALITY IMPROVEMENT PROGRAM DESCRIPTION 1998 • Senior Vice President of Health Services Chief Medical Officer of PHS • Regional Vice President and/or Plan President, Chairperson • Consumer Representative (3) 8.2 Senior Executive Management Committee (SEMC) Policy Statement: The PacifiCare of Colorado Senior Executive Management Committee directs and approves the allocation of financial and other resources for implementation of the QI program. Responsibilities and Functions: Functions of the SEMC include, but are not limited to, the following: • Establish direction and strategy for QI initiatives and operations • Allocation of financial and staff resources for QI initiatives • Oversee consistency of financial operations as it impacts the QI program • Integrate QI initiatives with other business processes and strategies • Identify duplicate processes and QI improvement activities to redirect or consolidate efforts within the market Composition of Senior Executive Management Committee: Membership of this committee includes, but is not limited to, the following: • Regional Vice President/Plan President/Chairperson • Vice President of Marketing and Sales • Vice President of Operations/Regional Service Center • Manager Regulatory Compliance (ad hoc0 • Vice President of Finance • Vice President of Provider Services • Director of Human Resources • Executive Vice President / Chief Operating Officer / Senior Medical Director • Vice President of Medical Management / Quality Improvement • Director of Communications • Vice President of Actuarial Services Page 13 Revision dates: 1993, 4-28-94, 3-10-93, 10-27-94, 1-19-95, 1-25-96, 3-27-97, 4-23-98 1:\QIPR0GRAM\Q1PR0-9843098 1998 05/26/98 9:06 AM PACIFICARE OF COLORADO QUALITY IMPROVEMENT PROGRAM DESCRIPTION 1998 • Area Vice President of Information Systems Frequency of Meetings: The SEMC meets on a weekly basis. Reporting Relationships: The SEMC reports to the Regional VP who is a member of the Board of Directors on a quarterly basis. The Chairperson of the SEMC will present the reports to the BoD. 8.3 Quality Improvement Committee (QIC) Policy Statement: The PacifiCare of Colorado Quality Improvement Committee retains the operational accountability for the design and implementation of the QI Program. It oversees the quality of service, operations and clinical care provided to PacifiCare of Colorado members. Responsibilities and Functions: Functions of the QIC include, but are not limited to, the following: • Report Quality Improvement activities to market Board of Directors and secondarily to the PHS National QI Committee. • Monitor performance and review reports from the Medical or Quality Improvement Directors, or PHS Health Services. • Ensure implementation and monitor performance on key quality of care and service indicators. • Review established quality of care and service indicators regularly. • Adopt clinical practice and preventive health guidelines. • Receive and review reports from other committees, including the Credentialing Committee, Service Solutions Committee, Peer Review Committee, Delegation Committee, Quality Improvement Projects Committee and Medical Management Committee. • Commission focused audits and quality improvement studies. • Recommend interventions for quality improvement. • Identify and develop strategies to reduce adverse outcomes. • Ensure and oversee the development and implementation of the QI/UM Program Description, Work Plan and Annual QI/UM Program Evaluation. Page 14 Revision dates: 1993, 4-28-94, 3-10-93, 10-27-94, 1-19-95, 1-25-96, 3-27-97, 4-23-98 1:\QIPR0GRAMQ1PR0-9843098 1998 05/26/98 9:06 AM PACIFICARE OF COLORADO QUALITY IMPROVEMENT PROGRAM DESCRIPTION 1998 • Develop and present comprehensive quarterly reports and the Annual QI Evaluation to the Board for its approval, comment and recommendations. • Review and approve market policies, as applicable to Quality Improvement. • Assess effectiveness and efficiency of Quality Improvement resource allocation and management. • Assess over/under utilization. • Review and approve clinical care management programs in collaboration with other departments. • Review and analyze trends for opportunities for improvement for member services. Composition of QI Committee: Representation on the QI Committee includes all appropriate departments to allow the Committee to serve as a forum for evaluating service and operations quality and integrating, coordinating and communicating ongoing QI activities across the Plan. Membership includes, but is not limited to, the following: Composition of QIC: • Vice President of Medical Management and QI/Medical Director and Chairperson • Quality Improvement Director • Director of Utilization Management (ad hoc participation from Corporate UM) • Submarket Medical Directors • Network Physicians • Health Improvement • Marketing and Sales • Provider of Delivery Systems • Pharmacy • Operations • Information Systems • Behavioral Health • Risk Management • Member Representative • Board Representative • Employer Group Representative Page 15 Revision dates: 1993, 4-28-94, 3-10-93, 10-27-94, 1-19-95, 1-25-96, 3-27-97, 4-23-98 1:\QEPROGRAM\QEPRO-9843098 1998 0526/98 9:06 AM PACIFICARE OF COLORADO QUALITY IMPROVEMENT PROGRAM DESCRIPTION 1998 • Chairs of Subcommittees • Quality Improvement Specialists • Research and Development Director Frequency of Meetings: The QIC meets on a monthly basis. Reporting Relationships: The QIC reports to the Board of Directors on a quarterly basis. The Chairperson of the QIC will present the reports to the BoD. 8.4 Credentialing Committee Policy Statement: The PacifiCare of Colorado Credentialing Committee is responsible for the review of physician files to ensure the accurate initial credentialing and ongoing recredentialing of PacifiCare of Colorado practitioners. Responsibilities and Functions: Credentialing Committee functions include, but are not limited to, the following: • Review, recommend, and approve procedures for practitioner/provider credentialing/recredentialing • Review and approve practitioner credentials. • Review and recommend provider/practitioner credentialing/ recredentialing information, including a corrective action plan, if necessary. • Review and approve a practitioner credentialing profile with input from all departments which analyzed performance in conjunction with the recredentialing process. • Review and approve credentialing/recredentialing standards. • Review and approve quality of care and service indicators for credentialing/recredentialing. • Identify sub -optimal care through the analysis of data referred from other departments. • Review and approve identified trends and opportunities for improvement and recommendations for strategies to prevent adverse outcomes. Page 16 Revision dates: 1993, 4-28-94, 3-10-93, 10-27-94, 1-19-95, 1-25-96, 3-27-97, 4-23-98 C\QIPR0GRAM\Q[PR0-9843098 1998 05/26/98 9:06 AM PACIFICARE OF COLORADO QUALITY IMPROVEMENT PROGRAM DESCRIPTION 1998 • Identify practitioners/providers not complying with Plan quality standards, service standards, guidelines and/or policies and procedures. • Review and approve corrective action plans for practitioners/providers in collaboration with other Plan departments. • Review and approve quarterly reports to the QIC. • Review and recommend a decision regarding physician alternate paths for specialty credentialing. • Review credentialing issues and refer recommendations to the QIC. Composition of Credentialing Committee: A minimum of 50% of members must be licensed, practicing physicians. Membership of this committee includes, but is not limited to, the following: • A minimum of 50% must be physicians • All Plan Medical Directors • Network Providers • Credentialing Director/Manager • Quality Improvement Director/Manager • Network Management Director/Manager • CVO representative (ad hoc) Frequency of Meetings: The Credentialing Committee meets on a monthly basis. Reporting Relationships: The Credentialing Committee reports to the QIC on a quarterly basis. 8.5 Quality Improvement Projects Committee Policy Statement: The PacifiCare of Colorado Quality Improvement Projects Committee is responsible for recommending, designing, implementing, and evaluating clinical QI initiatives and health promotion projects. Page 17 Revision dates: 1993, 4-28-94, 3-10-93, 10-27-94, 1-19-95, 1-25-96, 3-27-97, 4-23-98 1AQEPR0GRAM\Q1PR0-98-43098 1998 05/26/98 9:06 AM PACIFICARE OF COLORADO QUALITY IMPROVEMENT PROGRAM DESCRIPTION 1998 Responsibilities and Functions: The functions of this Committee include, but are not limited to, the following: • Conducts annual population analysis of market's members. • Reviews data from population analysis, membership, utilization, clinical epidemiology, and preventive health and recommends clinical Quality Improvement initiatives to the QIC. • Develops and implements study design, methodology, data collection, statistical analysis, project plans, and follow-up activities for approved clinical Quality Improvement projects. • Receive, review and approve reports from Pharmacy and Therapeutics Committee on a biannual basis. • Selects and establishes performance goals and monitors plan -wide clinical and pharmaceutical indicators. • Integrates clinical Quality Improvement, health promotion, and wellness projects. Composition of Quality Improvement Projects Committee: Membership of this committee includes, but is not limited to, the following: • Plan Medical Directors • Quality Improvement Management Specialists • Health Improvement Representative • NCQA Project Manager • Pharmacy • Director of Quality Improvement • Representative of Provider Services • Director of Medical Management • Studies Group Representative • Representative from Health Management Frequency of Meetings: The Quality Improvement Projects Committee monthly. Reporting Relationships: The Quality Improvement Projects Committee reports to the QIC bi- monthly. Page 18 Revision dates: 1993, 4-28-94, 3-10-93, 10-17-94, 1-19-95, 1-15-96, 3-27-97, 4-23-98 I:\QEPR0GRAM\Q1PR0-98-43098 1998 05/26/98 9:06 AM PACIFICARE OF COLORADO QUALITY IMPROVEMENT PROGRAM DESCRIPTION 1998 8.6 Peer Review Committee Policy Statement: The PacifiCare of Colorado The Peer Review Committee (PRC) consists of contracted physicians who represent the provider network, regional Quality Improvement Program staff, and regional Provider Relations representatives. Each PRC has a physician chairperson PacifiCare Medical Director appointed by the Quality Improvement Committee. Each PRC is responsible for the operational implementation of the QI Program and Work Plan within their respective market or geographic area as it relates to Peer Review. Responsibilities and Functions: The functions of the Peer Review Committee include, but are not limited to, the following: • Identify quality of clinical care issues through the review of medical charts and Quality Improvement data • Review and evaluate Quality Improvement findings • Report Quality Improvement activities to the Quality Improvement Committee and establish corrective action plans as needed. • Provide input to policy and procedure development related to benefits issues, and technology assessment requirements. • Educate the provider network regarding Quality Improvement activities. • Make recommendations for development and approval of Clinical Practice Guidelines and Preventive Health Guidelines to the QIC. • Serve as link between the QIC and the field-based/market clinical staff. • Operationalize implementation of the QI Program and Work Plan within the market as it relates to Peer Review Committee Composition of Committee: Representation on the Peer Review Committee includes, but is not limited to: A Plan Medical Director appointed by QIC (Chairperson) Contracted physicians representing the provider network Regional Quality Improvement Program staff Page 19 Revision dates: 1993, 4-28-94, 3-10-93, 10-27-94, 1-19-95, 1-25-96, 3-17-97, 4-23-98 C \Q IPROGRAMIQIPRO-9843098 1998 05/26/98 9:06 AM PACIFICARE OF COLORADO QUALITY IMPROVEMENT PROGRAM DESCRIPTION 1998 • Regional Network Management representatives Frequency of Meetings: The Peer Review Committee meets on a quarterly basis. Reporting Relationships: The Peer Review Committee reports to the QIC on a biannual basis. 8.7 Medical Management Committee Policy Statement: The PacifiCare of Colorado Medical Management Committee reviews Utilization Management activities, technology assessment activities and practice patterns for direct contract providers and for those providers for whom PacifiCare performs Utilization Management functions. Responsibilities and Functions: The functions of the Medical Management Committee include, but are not limited to, the following: • Review and approve UM Program Description and Annual UM Program Evaluation of the program as delegated by the QIC. • Analyze trends and develop medical management cost containment programs. • Review and approve UM criteria for assessing medical necessity of care. • Review and approve UM standards and communication to providers, members and staff. • Evaluate non -delegated participating physician practice patterns, provide feedback, and review/approve corrective action plans, as needed. • Assess effectiveness and efficiency of resource, allocation and management. • Review and approve UM policies/procedures. • Assess over -and under -utilization. • Review trends and develop strategies to reduce adverse outcomes. • Review, approve, and report quality of care service indicators for UM. Page 20 Revision dates: 1993, 4-28-94, 3-10-93, 10-17-94, 1-19-95, 1-25-96, 3-27-97, 4-23-98 1:\QIPR0GRAM\QIPR0-98-43098 1998 05/26/98 9:06 AM PACIFICARE OF COLORADO QUALITY IMPROVEMENT PROGRAM DESCRIPTION 1998 • Review and approve Technology Assessment procedures including new applications of existing technologies. (Report will originate from Health Care Standards and Education Committee.) • Review and approve clinical care management programs in collaboration with other departments. • Review and approve communication of standards, policies and procedures, and guidelines to providers, members and staff. • Review and approve medical policies in relation to coverage or payment of services • Review and approve quarterly reports to the QIC. Composition of Medical Management Committee: Membership of this committee includes, but is not limited to, the following: • Plan Medical Directors • Utilization Management Directors • Quality Improvement Representative • Health Improvement • Behavioral Health representative, ad hoc • Plan participating physicians including, but not limited to the following: • Family Practice • Internal Medicine • OB/GYN • Specialties and determined locally • Ad hoc: PHS VP, Corporate UM or designee, PacifiCare Behavioral Health Improvement Representatives • Provider Delivery System, Directors Frequency of Meetings: The Medical Management Committee meets at least on a monthly basis. Reporting Relationships: The Medical Management Committee reports to the QIC monthly. Page 21 Revision dates: 1993, 4-28-94, 3-10-93, 10-27-94, 1-19-95, 1-25-96, 3-27-97, 4-23-98 1:\QIPR0GRAM\QIPR0-98-43098 1998 05/26/98 9:06 AM How do the above charges differ assuming you are selected to administer all plans? -* Included in administrative fees. Note: (1) The costs of postage, telephone service, and printing of forms are assumed to be included in your fees. If not, please so note. (2) Charges for all required reports are to be included in the monthly fees. (3) Booklets and certificate preparation and distribution must be included in your fees. (4) Indicate any charges for customized identification cards. $ * /card (5) Indicate if Retiree Administration (sending election notices, etc.) is a separate charge. b Not available You may request a copy of RFP P686, Claims Administrator Services, after June 26, 1998. * Depends upon customization required. ID cards already have company name, group number and benefits. PACIFICARE OF COLORADO QUALITY IMPROVEMENT PROGRAM DESCRIPTION 1998 8.8 Delegation Committee Policy Statement: The PacifiCare of Colorado Delegation Committee is responsible for the oversight of all delegated activities of service activities. Responsibilities and Functions: • Review and approve delegated policies and procedure including workflows. • Review and approve provider/practitioner criteria for network participation. • Prioritize delegated service initiatives focusing on customer service improvements. • Review and analyze current and past delegated service initiatives or changes in process to determine effectiveness and future opportunities for improvement. • Provide oversight to provider delegated activities. • Provide reports to Medical Management on matters of provider network performance. • Report to the QIC regarding delegation decisions. • Approves all delegation status. • Review, approve and report corrected action plans to QIC. Composition of Delegation Committee: The membership of this committee should include, but is not limited to the following: • Plan Medical Director and representatives from: • Provider Delivery System • Utilization Management • Quality Improvement • Legal/Regulatory • Finance • Claims • Customer Services • Marketing and Sales • Quality Improvement Subcommittees • BRC • Provider Reporting Page 22 Revision dates: 1993, 4-18-94, 3-10-93, 10-27-94, 1-19-95, 1-25-96, 3-27-97, 4-23-98 1:\QIPR0GRAM\Q1PR0-9843098 1998 05/26/98 9:06 AM PACIFICARE OF COLORADO QUALITY IMPROVEMENT PROGRAM DESCRIPTION 1998 Frequency of Meetings: The Delegation Committee meets on at least a monthly basis. Reporting Relationships: The Delegation Committee should report to the QIC on at least a bi-monthly basis. 8.9 Service Solutions Committee Policy Statement: The PacifiCare of Colorado Service Solutions Committee is responsible for oversight of internal service quality for members and regularly reporting its findings and actions to the QIC. Responsibilities and Functions: • Reviews customer service performance indicators. • Identifies trends and recommends strategies to reduce grievances and complaints and to increase member satisfaction and improve service to member. • Identify appropriate benchmarks for designated internal service indicators. • Reviews, initiates and prioritizes internal service initiatives. • Analyzes current and past service initiatives or changes in process to determine effectiveness and next appropriate steps. • Recommends process improvements based on service priorities. Composition of Service Solutions Committee: Membership of this committee includes, but is not limited to, the following: • Provider Delivery Systems • Claims • Customer Services (Commercial and Secure Horizons) • Sales and Services (Commercial and Secure Horizons) • Quality Improvement • Regulatory Compliance (Commercial and Secure Horizons) Page 23 Revision dates: 1993, 4-28-94, 3-10-93, 10-17-94, 1-19-95, 1-25-96, 3-17-97, 4-23-98 I:\Q[PR0GRAM\Q1PR0-98-43098 1998 05/26/98 9:06 AM PACIFICARE OF COLORADO QUALITY IMPROVEMENT PROGRAM DESCRIPTION 1998 • Risk Management • Research and Development • Membership Accounting Services • Medical Management • Provider Reimbursement (ad hoc) • Plan Medical Director Frequency of Meetings: The Service Solutions Committee meets on at least a monthly basis. Reporting Relationships: The Delegation Committee should report to the QIC on at least a quarterly basis. 8.10 Member Relations Committee Policy Statement: The PacifiCare of Colorado Appeals and Grievances Committee is responsible for providing oversight to the appeals and grievance process that operates between the Regional Customer Service Center and the health market. Responsibilities and Functions: • Support the analysis of any appeal, convene second level hearings, and otherwise facilitate the completion of any appeal. • Prepare a written response to the member. • Review and analyze appeals and grievances trends (plan -wide and by individual provider groups) on a quarterly basis. • Monitor timeframes to assure that the appeals and grievances process meets plan standards. • Assure consistency in the interpretation and processing of appeals and grievances. • Identify barriers and opportunities for improvement. Composition of Member Relations Committee: Membership of this committee includes, but is not limited to, the following: • A Plan Medical Director • Risk Manager Page 24 Revision dates: 1993, 4-18-94, 3-10-93, 10-27-94, 1-19-95, 1-25-96, 3-17-97, 4-23-98 1AQIPR0GRAM\QIPR0-98-43098 1998 05/26/98 9:06 AM PACIFICARE OF COLORADO QUALITY IMPROVEMENT PROGRAM DESCRIPTION 1998 • UM Representative • Provider Delivery Systems • Membership accounting Services • Manager of Regulatory Compliance • Marketing and Sales • Vice President of Medical Management/Quality Improvement • Underwriting • Principle Member Advocate (PMA) • Customer Services • Claims Frequency of Meetings: The committee should meet as required for the resolution of grievances in a timely fashion, but no less than weekly. Reporting Relationships: The committee should report to the Service Solutions Committee on at least a bi-monthly basis. 9.0 Committee Guidelines 9.1 Meeting Minute Format: All committee meetings shall be conducted according to a formal agenda. Formal minutes shall record committee deliberations and actions. The format for minutes shall be approved by the QIC. Specific minutes must document: • Meeting date, location and attendance • Review of actions from previous meetings • Summary of discussions and deliberations • Recommendations • Actions to be taken • Responsible party • Due dates for follow-up activities 9.2 Meeting Minute Content: Committees shall comply with the following guidelines: • Reflect objectively what happened at a meeting and not interpretation of the proceedings • Reflect and clearly state the points made • Use complete sentences, proper language and grammar Page 25 Revision dates: 1993,4-18-94, 3.10-93, 10-27-94, 1-19-95, 1-25-96, 3-27-97, 4-23-98 I:IQ1PR0GRAM\QIPR0-98-43098 1998 05/26/98 9:06 AM PACIFICARE OF COLORADO QUALITY IMPROVEMENT PROGRAM DESCRIPTION 1998 • Differentiate between findings, discussions, conclusions, recommendations and actions 9.3 Voting/Quorums: Committees shall follow parliamentary procedures. Decision making shall comply with the following guidelines: • Decisions are made by majority vote • The Medical Director's vote will prevail in case of a tie • A quorum is 50% of the voting members of the committee in attendance plus one 9.4 Membership Selection/Attendance: • The PacifiCare of Colorado Vice President of Medical Management & Quality Improvement / Medical Director or designee will recommend committee members to the QI Committee, Credentialing Committee, Service Solutions Committee and Medical Management Committee, etc. • A portion of the physician members shall be rotated at least every two years • Each committee member serves for the duration assigned to a position, as specified by the committee • Members are required to attend 70% - 80% of the meetings to remain eligible for continued participation • Frequency of committee meetings will vary according to the scope and functions of the Committee 10.0 Roles/Responsibilities 10.1 Regional Vice President The Regional Vice President of the Central Region oversees the QI Program by reviewing reports from the PacifiCare of Colorado QI Committee. As a member of the PacifiCare of Colorado Board of Directors, the Regional Vice President participates in the review and approval of the Annual QI Program, QI Evaluation and QI Work Plan for the calendar year. Performance accountabilities include, but are not limited to, the following: • Establishment of direction and strategy for the Region • Establishment of consistency in the QI structure for committees and leadership Page 26 Revision dates: 1993, 4-18-94, 3-10-93, 10-27-94, 1-19-95, 1-25-96, 3-27-97, 4-23-98 1AQIPR0GRAM\QIPR0-98-43098 1998 05/26/98 9,06 AM PACIFICARE OF COLORADO QUALITY IMPROVEMENT PROGRAM DESCRIPTION 1998 • Determination of regional operating structure • Allocation of resources • Evaluation of performance consistent with corporate goals • Integration of QI initiatives with other business processes and strategies 10.2 President of PacifiCare of Colorado The President oversees operations within PacifiCare of Colorado. This oversight encompasses Health Services, Quality Improvement, Contracting, and Commercial/ Secure Horizons Sales. Performance accountabilities for the QI Program include, but are not limited to, the following: • Provide direction and leadership in the identification and improvement of problems in all departments that impact Plan operations • Recommend follow-up and action within the appropriate QI Committee • Allocate staffing resources to ensure operational efficiency and effectiveness • Ensure compliance with regulatory and accreditation requirements • Accountable for PacifiCare of Colorado financial results • Evaluate performance against regional and corporate goals. 10.3 PacifiCare of Colorado Medical Director The PacifiCare of Colorado Vice President of Medical Management & Quality Improvement / Medical Director is accountable for providing leadership within the QI Program. The Director of Quality Improvement Director of Utilization Management, Director of Pharmacy, Director of Operations, and Submarket Medical Directors report directly to the PacifiCare of Colorado VP Medical Management & QI/Medical Director. Performance accountabilities for the VP of Medical Management & QI / Medical Director and Submarket Medical Directors include, but are not limited to, the following: • Monitor the implementation of the QI process as it relates to quality of care and assure that corrective actions are taken when problems are identified Page 27 Revision dates: 1993, 4-28-94, 3-10-93, 10-27-94, 1-19-95, 1-25-96, 3-27-97, 4-23-98 1AQIPR0GRAMlQEPR0-98-43098 1998 05/26/98 9:06 AM PACIFICARE OF COLORADO QUALITY IMPROVEMENT PROGRAM DESCRIPTION 1998 12.0 Confidentiality 12.1 Policy Statement: All employees and agents of PacifiCare and the employees and agents of all contracting practitioners will maintain the confidentiality of member information, medical record, peer review and quality improvement records. They also will assure that such information and records are not, either inadvertently or purposefully improperly disclosed, lost, altered, tampered with, destroyed or misused in any manner. All information used for QI activities is maintained as confidential in accordance with applicable federal and state laws and regulations. Employees shall sign a Confidentiality Statement. Any breach in confidentiality may result in disciplinary action. 12.2 QI Committee Members: Participation on all PacifiCare of Colorado QI Program committees requires a signed Confidentiality Agreement on an annual basis. This agreement allows for free, candid and objective discussion necessary for effective management. This agreement has been reviewed by PacifiCare of Colorado legal counsel in regards to the protection of peer review activity. The agreement notes that the signer holds an obligation of strictest confidence which shall survive the termination of membership on PacifiCare's committees. If a staff member or contracting provider is on more than one committee, the confidentiality statement for that individual can reflect all committees on which the member participates. 12.3 Access to Information: Access to member or provider -specific peer review QI information shall be restricted to those individuals and/or committees charged with responsibility for peer review activities. Authorization from the PacifiCare of Colorado Medical Director for the release of information collected through QI activities to outside parties must be obtained in advance with legal consultation. Such releases will in no instances contain member identifiers. Use of QI information for other than described QI purposes must also be authorized by the PacifiCare of Colorado Medical Directors. Release of all information will be in accordance with Colorado and Federal laws. 12.4 Meeting Materials/Minutes: All QI meeting materials and minutes shall be considered confidential and processed in a manner designed to ensure confidentiality: Page 32 Revision dates: 1993, 4-28-94, 3-10-93, 10-27-94, 1-/9-95, 1-25-96, 3-27-97, 4-23-98 I:\Q1PR0GRAM\Q1PR0.98-43098 1998 05/26/98 9:06 AM PACIFICARE OF COLORADO QUALITY IMPROVEMENT PROGRAM DESCRIPTION 1998 • Participate in the development and design of the QI Program • Participate in the Annual QI Program Evaluation • Evaluate Plan studies and assist in the development of corrective action plans • Monitor implementation of the QI, UM, and Credentialing programs in cooperation with committee chairs • Chairperson of the Medical Management Committee. Chairs the QIC. Recommends chairs of Peer Review, Credentialing, Quality Improvement Projects Committee, Service Solutions Committee, Member Relations Committee. • Member of Senior Executive Management Committee. Quality Improvement Committee, Medical Management, Quality Improvement Projects Committee, Member Relations Committee. • Coordinate with contracted Provider Group Medical Directors in QI, UM, Health Education/Wellness, as applicable • Coordinate and communicate peer review information and decisions to network physicians • Participate in development of the QI Program, QI Work Plan, UM Program and Credentialing program • Perform individual clinical case review (including grievances and appeals) and make corrective action recommendations on quality of care issues • Review medical necessity denials • Oversee UM inter -reviewer reliability process • Evaluate clinical studies and assist in development of corrective action plans • Analyze UM data and establish priorities for focused studies (high volume, high risk and high cost areas) in cooperation with the Medical Management Committee • Contribute to development, review and dissemination of clinical studies and practice guidelines/standards to participating providers • Review of all clinical indicators for ambulatory and inpatient care 10.4 Director of Quality Improvement The PacifiCare of Colorado Director of QI is accountable for implementation of the QI Program. This accountability involves planning and collaboration of QI activities utilizing QI, Credentialing and Health Service staff to support initiatives. Support from other Page 28 Revision dates: 1993, 4-28-94, 3-10-93, 10-27-94, 1-19-95, 1-25-96, 3-17-97, 4-23-98 1:\Q1PR0GRAM\Q0?R0-98-43098 1998 05/26/98 9:06 AM PACIFICARE OF COLORADO QUALITY IMPROVEMENT PROGRAM DESCRIPTION 1998 departments within the Market, Regional and Corporate offices is coordinated to maximize program efforts. The Quality Management Specialists, Manager of Risk Management, and Manager of Health Improvement report directly to the Director of QI. Performance accountabilities for the QI Director include: • Coordinate and communicate QI activities throughout the PacifiCare of Colorado health care delivery system • Provide education on QI principles at all levels of the organization • Ensure compliance with Colorado, Federal and accreditation body requirements • Coordinate development, implementation and revision (as appropriate) of QI policies and procedures • Coordinate development of Annual QI Program Evaluation, Annual QI Work Plan and revision as necessary to the QI Program Description. • Coordinate departmental performance indicator reporting to the Clinical QI Committee and the Corporate QI Committee • Oversee the performance, analysis and reporting of audit, study and survey activity • Monitor and participate in Health Education/Wellness Program development • Coordinate tracking, analysis and reporting of risk management and potential quality of care issues • Facilitate identification of opportunities to improve the quality of care and service PacifiCare of Colorado members receive • Oversee development and implementation of the PacifiCare of Colorado delegation program • Monitor Plan compliance with the delegation program and specific delegated functions in conjunction with the Peer Review Committee • Assist in the development, communication and implementation of Medical Director and QI Committee decisions and/or corrective action plans • Participate in contracted provider operations meetings as needed • Manage the process for investigation and resolution of member grievances related to potential quality of care issues • Facilitate preparation of quarterly QI reports • Develop and manage annual QI budget including budget variances Page 29 Revision dates: 1993, 4-28-94, 3-10-93, 10-27-94, 1-19-95. 1-25-96, 3-27-97, 4-23-98 IaQ1PR0GRAM\QIPR0-98-43098 1998 05/26/98 9:06 AM PACIFICARE OF COLORADO QUALITY IMPROVEMENT PROGRAM DESCRIPTION 1998 • Facilitate standardization of benefits and Technology Assessment Committee to meet the needs of the Plans. 11.0 Delegation PacifiCare of Colorado does not delegate Quality Improvement, Members' Rights and Responsibilities, or Preventive Health activities at the present time. PacifiCare of Colorado may delegate Utilization Management, Credentialing, and Medical Record activities to entities which meet PacifiCare standards for delegation. Components of Utilization Management are delegated to specified medical groups and Managed Behavioral Health Organizations (MBHOs) as described in the Utilization Management Program Description. The primary source verification component of credentialing is delegated to an NCQA certified Credentialing Verification Organization (CVO). Entities performing Credentialing, Utilization Management and/or Medical Record activities on behalf of PacifiCare of Colorado must satisfy the Plan's standards for delegation. Entities that will be considered for delegation include, but may not be limited to, the following: - Hospitals - IPAs - Medical Groups - Behavioral Health Providers - Chiropractic Networks - Vision Care Networks - Credentials Verification Organizations (CVOs) The Delegation Committee is responsible for overseeing and approving delegated activities. PacifiCare of Colorado has policies and procedures in place to ensure delegated provider compliance with PacifiCare standards. PacifiCare retains accountability for all delegated functions and conducts annual oversight of all delegated entities. If PacifiCare for any reason believes that delegated functions are not being carried out in accordance with the terms of the contract/letter of agreement, corrective action, up to and including revocation of, delegated status may be implemented. Page 31 Revision dates: 1993, 4-28-94, 3-10-93, 10-17-94, 1-19-95, /-25-96, 3-27-97, 4-23-98 C\QIPROGRAM\Q 1PR0-9843098 1998 05/26/98 9:06 AM TPA SERVICES QUESTIONS TO BE ANSWERED Claims Administration 1. From what city will claims be administered? Claims are processed at the Englewood PacifiCare building. 2. What are your normal business hours? Customer Service business hours are from 7:00 AM - 6:00 PM Monday through Friday. 3. How long have you administered managed care plans? Define dates, as applicable, for each network plan. HMO 1 1974 PPO 7 1989 POS 1989 1. Do you provide in -state and/or national WATS telephone service? What, if any, are the additional charges for this service? PacifiCare of Colorado has an in -state WATS line at (800)877-6685. There is no additional charge for this service. Customer Service can be reached at (800)877-9777. 2. Describe your company's performance standards with respect to: a. employee inquiries (both written and telephonic) b, claims turnaround C. claims accuracy Please indicate your actual performance during the 1997 calendar year in attaining these standards. Standard Actual ��'erfornlanccll Employee inquiries Measured by ultimate resolution only 100% within 60 days Claims turnaround 85 % within 30 days 19.1 working days Claims accurac 95% 98.56% W PACIFICARE OF COLORADO QUALITY IMPROVEMENT PROGRAM DESCRIPTION 1998 • Assist Marketing with requests for proposal information and Plan sponsor presentations 10.6 Contracted Practitioners/Providers Contracted practitioners/providers serve on Plan QI Committees based on membership served and specialty practiced. Their role includes, but is not limited to: • Supporting fair and reasonable credentialing and recredentialing decisions • Presenting the viewpoint of the practicing physician in discussions about clinical QI activities and intervention strategies • Performing peer review of cases of suspected instances of poor quality • Providing input for the development and revisions of preventive health and clinical practice guidelines • Making recommendations on potential areas of focus for clinical QI initiatives 10.7 PacifiCare Health Systems Corporate Quality Improvement PacifiCare Health System's role in quality improvement is to monitor, consult as needed, and report on a national basis the QI activities of the individual PacifiCare Plans. PHS QI staff have expertise in data analysis, clinical practice, legal and regulatory affairs, policy and procedure development and QI functions that support a comprehensive QI program. The role of Corporate QI includes but is not limited to, the following • Develop policies and procedures or templates • Develop Wellness, Demand Management and Chronic Care Program templates in addition to other quality initiatives • Develop nationwide benchmarking data for PacifiCare Plans • Assist with the development, data analysis and documentation of QI studies • Report best practices among PacifiCare Plans • Facilitate communication and sharing of ideas among PacifiCare Plans • Assist with regulatory and accreditation survey preparation Page 30 Revision dates: 1993, 4-28-94, 3-10-93, 10-27-94, 1-19-95, 1-15-96, 3-17-97, 4-23-98 1:\Q1PR0GRAM\Q1PR0-9843098 1998 05/26/98 9:06 AM PACIFICARE OF COLORADO QUALITY IMPROVEMENT PROGRAM DESCRIPTION 1998 • Statements denoting "Confidentiality" or "Confidential" must be written on all reports, studies and documents for a committee's review • Committee minutes must be maintained in a locked cabinet or file room • Meeting minutes must not be included as an attachment to Board minutes • Distribution of minutes shall be restricted to members of the Committee 13.0 Risk Management The PacifiCare of Colorado QI process includes a mechanism for reviewing potential risk cases to identify quality related concerns. Plan personnel and delegated Physician Medical Groups are responsible for identifying, reporting and documenting risk management and potential quality of care problems. The QI Director, or designee, is responsible for assessing and coordinating investigative activities, and tracking and trending results. The Manager of Risk Management is responsible for reporting all potential risk management issues to the Plan's legal counsel. On a prospective basis the Plan evaluates practitioner applicants through the credentialing process, and conducts evaluation and oversight of delegated activities. 14.0 Annual Update of Program Description The Medical Director ensures that the PacifiCare of Colorado Program Description is reviewed at least annually and updated more frequently as appropriate. The QIC is accountable for approving the QI Program Description during the first quarter of each calendar year. The QI Program Description is presented for review and approval to the BoD by the PacifiCare of Colorado Medical Director. 15.0 Annual QI Program Evaluation The Quality Improvement Program shall be evaluated on an annual basis. The evaluation will address all aspects of the quality improvement process as outlined in the Program Description. The evaluation will be presented to the QIC and to the Plan Board of Directors for approval. Programs/initiatives still in Page 33 Revision dales: 1993, 4-28-94, 3-10-93, 10-27-94, 1-19-95, 1-25-96, 3-27-97, 4-23-98 1AQ1PR0GRAM\Q1PR0-9843098 1998 05/26/98 9:06 AM PACIFICARE OF COLORADO QUALITY IMPROVEMENT PROGRAM DESCRIPTION 1998 progress or requiring ongoing monitoring will be incorporated into the QI Work Plan for the upcoming year. 16.0 Annual Work Plan An Annual QI Work Plan shall be developed during the first quarter of each year with input from functional areas and the QI Committees. The QI Work Plan shall identify QI goals and objectives, areas of program focus, and the specific QI related activities and programs that are to occur. Action steps include target date for completion and responsible party. Activities include tracking of previously identified issues and planned evaluation of the QI Program. The QI Work Plan shall be submitted to the QIC and to the Plan Board of Directors for approval. The PacifiCare of Colorado 1998 QI Work Plan can be found in Appendix B. 17.0 QI Program Integration PacifiCare of Colorado is committed to the integration of QI activities throughout the market. The single most important factor in this integration is the representation of a multi -disciplinary team on the QIC. Membership on this committee represents all functional areas of the Plan, including, but not limited to: Plan Medical Director, QI, UM, Health Improvement, Marketing, Claims, Pharmacy, Operations, Member Services, IS, Behavioral Health, Credentialing and Provider Relations. 18.0 Disclosure The QI Program Description and Work Plan will be provided to all Plan committee members and Plan staff. Information regarding the PacifiCare of Colorado QI Program will be made available to Plan providers through the Provider Manual and to enrollees, upon request. Page 34 Revision dates: 1993, 4-28-94, 3-10-93, 10-27-94, 1-19-95, 1-15-96, 3-17-97, 4-23-98 1:\QIPR0GRAM\Q1PR0-9843098 I998 05/26/98 9:06 AM No Text CLAIM HISTORY INQUIRY PATIENT CLAIM NUM PAID DATE CHECK NUM FROM TO CHARGES P 1709728868 H 05/23/97 0200773771 03/01/97 03/20/97 7929.20 P 1706629027 H 04/14/97 0200766739 02/24/97 02/28/97 549.30 P 1709129192 H 05/23/97 0200773428 02/24/97 02/24/97 60.28 P 1705805108 D 04/22/97 0200768548 02/17/97 02/17/97 116.00 P 1711506687 D 05/11/97 0200772702 02/17/97 02/17/97 116.00 P 1705029677 H 03/18/97 0200760459 02/05/97 02/05/97 174.30 P 1704509870 D 03/18/97 0200760575 02/04/97 02/04/97 69.00 P 1708606494 D 04/14/97 0200766561 02/04/97 02/04/97 69.00 P 1706929458 H 04/14/97 0200766471 02/03/97 02/26/97 1115.68 P 1706969437 H 06/24/97 0200780662 01/31/97 02/03/97 267.27 P 1813829438 H 06/10/98 0200853553 01/31/97 02/03/97 267.27 P 1703605239 D 03/04/97 0200757641 01/27/97 01/27/97 32.00 P 1703605240 D 03/04/97 0200757641 01/27/97 01/27/97 3342.30 P 1703107793 D 03/04/97 0200757641 01/24/97 01/24/97 116.00 P 1703129109 H 03/04/97 0200756768 01/16/97 01/16/97 174.30 P 1702714682 D 02/24/97 0200755216 01/15/97 01/15/97 69.00 E 1703584734 D 02/18/97 0200754298 01/15/97 01/15/97 63.00 P 1701011547 D 03/04/97 0200757641 01/06/97 01/06/97 38.50 MARK CLAIMS WITH 'X' -- PRESS <PF1><,> TO DISPLAY DETAIL PROVIDER NAME PIKES PEAK HOS PIKES PEAK HOS PENROSE HOSPIT ROBERT SAYRE M ROBERT SAYRE M PENROSE HOSPIT COLORADO SPGS COLORADO SPGS PENROSE COMMUN PENROSE COMMUN PENROSE HOSPIT ROBERT SAYRE M ROBERT SAYRE M ROBERT SAYRE M PENROSE HOSPIT COLORADO SPGS DENNIS SCHNEID ROBERT SAYRE M No Text 1998 Profile for Recredentialing Thursday, April30, 1998 ivider ID(s): Specialty: Family Practice Region: DW Denver Metro Region Plan Start Date: 1011194 Practice Open: y Commercial Members: Advantage 65 Members: Medisupp 65 Members: 151 0 0 HMO Network I PPO Network Avista Senior Plan © Denver West Senior Plan emu❑ ©St Anthony Central Sr Plan El St Anthony North Sr Plan ❑ ElSPC Kodak "'�;IpO Plus Members: g Longmont Senior Plan g ❑ Boulder Senior Plan ❑ Individual Members: i Z i Co Springs Senior Plan ElAurora/Pres Senior Plan El Medicare Suppliment Members: 3 Penrose/SF Senior ElP/SL Plan Senior Plan El 50/50 Members: 1 CSHP Senior Plan Rose Senior Plan El Self Funded POS Members: p Pueblo Senior Plan ElPorter Senior Plan ❑ Sr Plan Members: 0 Total# Members: St. Mary Senior Plan ❑ UPI-PSV Eli of 165 Doctor Bedside manner -Attitude/Petsonality/Conflict/Consideratc/etc 5 Long wait time for an appointment 2 Total: 7 1995 19% Eligible Members: 0 / NQI 1.11 L-2 L-3 Pend Total Compliant members: 0 r 19% 0 0 0 0 0 C Compliance: 0 too 1997 0 0 0 0 0 1998 Profile for Recredentialing Thursday, April 30, 1998 tz Overall DPT OPV Measles Mumps Rubella HIB Eligible Members: O 0 p D pliant members: O O Q p 0 � O % Compliance: O 0 J : Overall DPT OPV MMR HIB HEP� -.1996 Eligible Members: 2 2 2 2 2 2 Compliant members: 0 1 1 1 0 0 % Compliance: 0.00% 50.00% 50.00% 50.00•A: 0.00% 0.00% i Member Grievance (Type of Grievance, Count of Grievance, # per 1000 members) µ- :i. _. ^4x. ?..nniw -y,„.,,y Gv46c� FHP Site Review Pre -Contract a � -720 CWL 1994 1"5 Eligibility No No ER Peer Average 9.02181709 8.71619883 ER Significant No No ER11000 members 0 29.4117647 Recredentialing and Litigation Information: Comments: Risk Commen FHP Site Review Ambulatory Care FHP Site Review Ambulatory Care Medical Records Withhold %: Utilization to funding: Cspitated: 030 Y PROF ENANT HEALTH PTNRS 1994 1995 1996 Vaginal 0 1 O C-Section 0 0 0 Total 0 1 0.00% 0,00% rJ % p�p No Text ROW, 11 Ra 6455 South Yosemite Street Englewood, Colorado 80111 Tel303-220-5800 July 27, 1998 Requesting Physician: DR. SERNA Attn: Fax #: 719-597-8703 Phone #: Member's Name: Member's Number: PacifiCare has authorized services, provided the member maintains coverage with PacifiCare, and the service does not exceed their benefit. PacifiCare has approved CT SCAN for your above referenced patients. Date of service: From: 7/15/98 Your authorization number is: 2920000 Medical Management: ❑ Monica Anaya ❑ Sheila Scanlan ❑ Eric Orblom ❑ Patty Bogert Q Lynette Washburn ❑ Cindy Ashley ❑ Gena Rodish ❑ Carol Costello To: 8114198 ❑ Alva Degner, R.N. ❑ Dave Hampton, R.N. ❑ Pam Kurth, R.N. ❑ Stacie Mauries, R. N. ❑ Tasha O'Flynn If you have additional questions, please feel free to contact PacifiCare's Precertification Department at 1-800-255-1189. THIS FORM MUST BE COMPLETED BY ALL PROPOSERS CITY OF FORT COLLINS, COLORADO PROPOSAL FORM COVERAGES QUOTING (Please check all that apply) CARVE -OUT MEDICAL PPO PRESCRIPTION DRUGS PPO POS EPO Stop - Network Network Network TPA UR Loss X X X X X X 1. Our proposal is valid for 90 days. 2. Fee/Rate Guarantee: PPO Network 12 months POS Network 12 months EPO Network 12 months TPA 12 months UR 12 months Stop -Loss 12 months Carve -Out PPO Prescription Drugs N/A months 3. Standard & Poor's Rating (if applicable): N/A: (AM Best Rating: A-) 4. Commissions: Yes _ No JL If yes: To whom $ /year 5. Contact Name (in case of questions regarding proposal): Stacv J. Stark Telephone Number: (303)714-3240 Fax Number: (303)714-3999 r 7 Carrier Name: PacifiCare of Colorado Complete the following: PacifiCare of Colorado COMPANY NAME July 29, 1998 PATE SIGNATURE Chris Lawrence PRINTED SIGNATURE Account Manaeer TITLE 6455 South Yosemite St. ADDRESS Englewood, CO 80111 CITY. STATE, ZIP CODE Arapahoe COUNTY (303)714-3463 TELEPHONE NUMBER (303)714-3999 I e111u10.1011 ANSWERS MUST BE PROVIDED FOR ALL ABOVE QUESTIONS ON THIS FORM. DO NOT REFERENCE ANOTHER SECTION OF THE PROPOSAL FOR YOUR RESPONSE. 6. Is your firm willing to incorporate guaranteed turnaround time, COB recovery and quality performance standards in its contract with the City? Please detail under what conditions and terms your company would be willing to negotiate. PacifiCare has developed a core set of performance standards, associated penalties and reporting that we would be willing to discuss with The City of Fort Collins as contract negotiations continue. COB recovery is not an item that is measured as part of these performance standards and will not be included. 7. Describe your company's quality assurance and/or internal audit procedures and programs. Are you willing to provide the client with quarterly audit reports on its claims? Are you willing to allow an annual audit to be performed by an external auditor? PacifiCare audits 3% of each claims processors work daily. New processors work is audited more frequently. If a mistake is found, a report is given back to processor which will show the following errors: 1. Statistical 2. COB 3. Episode/Referral 4. Payment 5. Contract/Policy PacifiCare's claims department overall accuracy standard is 98%. Focused audits are conducted on an ongoing basis, and delegated provider groups will be audited to ensure PacifiCare standards are being met. We would allow an annual audit by an external auditor. 8. Describe your organization's errors and omissions insurance. Managed Care Errors and Omissions Carrier: Texas Farmers Insurance $10,000,000 9. Describe in detail your claims adjudication hardware and software systems, and in particular, your claims editing capabilities. Specifically, address how it checks for procedural discrepancies based on diagnosis, diagnostic "creep", duplication of claims and procedural unbundling. What percent of claims are detected by these edits? What percent of dollars claimed? How do you treat claims detected as a result of these edits? Is this software/hardware capable of producing special reports, tapes, data transfers that may be requested by the City. If so, is there an additional expense for these requests? List costs. PacifiCare's EPO integrated information platform is known as IIdAD. The "core" of transaction processing utilizes the Health Claims Processing System from Digital Insurance Systems Corporation of Columbus, Ohio. This software is integrated with Claim check, from GNUS out of Philadelphia, Pennsylvania. The system was installed as a packaged system with significant custom modifications applied by PacifiCare personnel. The system constraints are programmed into both Iliad and RIMS to flag procedural discrepancies. We also utilize a program called "Claim Check", an automated system to evaluate claims to identify irregularities such as unbundling of procedures, incorrect coding practices and to ensure that CPT guidelines are being applied consistently. 20 No Text Member Complaints If a member is not satisfied with services or benefits received from PacifiCare, the member is asked to contact the Customer Services Department initially and an attempt will be made to resolve concerns through an internal issue resolution process. Member Appeal Process If the member is not satisfied with the resolution and wishes to pursue the issue further, the member must submit a written request to initiate the member appeal process. Written requests should be directed to the PacifiCare Member Appeals Team. Department Review The PacifiCare Customer Service Department will attempt to resolve such written requests through research by the appropriate department to determine if criteria and processes have been administered correctly. The member will be notified of the resolution usually no later than thirty- one (31) days after PacifiCare receives the request. If the member is not satisfied with the decision, a written request must be submitted within ninety (90) days of the review determination to initiate the next level (Level I) of the Member Appeal Process. If the next step of the process is not initiated by the member as explained above, the action or claim denial will be final. Member Relations Committee Review The Member Relations Committee will provide a formal review and respond to the member within thirty-one (31) days after receiving the request. If the member is not satisfied with the decision of the Member Relations Committee, the member can request a review by a Formal Member Appeals Panel if new or additional information becomes available, and a written request is submitted to PacifiCare within thirty-one (31) days of the Member Relations Committee determination. If a written request is not submitted, then the action or claim denial will be final. Formal Member Appeals Panel Review Only if new or additional information becomes available, may members submit a written request for review by a Formal Member Appeals Panel. This Panel consists of individuals and providers (both internal and external) who have knowledge of the benefit and medical areas involved in the matter. The member is invited to meet with the Panel to present the issue. A written determination of the Panel's findings is then sent to the member within thirty-one (31) days of the Panel meeting. Arbitration If a member is not satisfied with the resolution of a legal claim after exhausting all levels of the formal member appeals process applicable to the claim, PacifiCare and the member agree that they shall submit the claim to binding arbitration in accordance with the Commercial Arbitration Rules of the American Arbitration Association unless both PacifiCare and the member agree in writing to use another form of alternative dispute resolution (e.g., mediation) as PacifiCare and the member may agree upon in writing. The results of the binding arbitration shall be final, with no further recourse in a court of law or otherwise available to either PacifiCare or the member. Judgment upon the award rendered by the arbitrator(s) shall be entered in any court having jurisdiction. PacifiCare and the member shall equally share the costs of arbitration; however, each party shall be individually responsible for the expenses related to its attorney, experts, and evidence. PacifiCare® Participating physicians have the right to make recommendations regarding policies they believe require change and/ or clarification. Procedure: 1. Providers must submit Policy and Procedure appeals in writing to their respective Provider Services Representative. 2. The Appeal should include extensive documentation as to why a specific policy needs to be amended. This could include, but is not limited to, publications, operative reports and specific examples that support their case. 3. The respective Provider Services Representative believes the appeal is valid and complete, it must be submitted to the Provider Appeals Committee using the attached cover sheet. The Provider Services Representative will send a letter to the provider informing him/her that FHP has received their appeal, and forwarded to the Provider Appeal's Committee for review. 4. Upon submission of the appeal to the Provider Appeal's Committee, the Provider Services Representative will notify the provider, in writing, that his/ her appeal has been received and is currently in the appeal process. 5. After determination is made on the Appeal, the Provider Services Representative must notify the provider in writing of the Committee's decision. a. If the providers' appeal is denied, the provider has the right to appeal the decision to the Columbine Medical Group Finance Committee, and ultimately to the Columbine Medical Group Board of Directors. The appropriate Provider Services Representative will be available to facilitate submission of the appeals to the CMG Finance Committee. b. If the providers' appeal is approved, the Provider Services Representative may be requested by the Provider Appeals Committee 1%dfiCWVa Pacif2Care ° July 22, 1998 Regarding member:. ID number: Regarding request for: Date of Service: Dear Ms. out of area emergency treatment PacifiCare of Colorado 5725 Mark Dabling Boulevard Colorado Springs, Colorado 80919 Tel 719-522-6000 This is in response to your request for Secure Horizons authorization of an out of area emergency treatment. Based upon the information provided, Secure Horizons has approved the out of area emergency treatment with Mid America Retina Consultants on This claim number will be reprocessed and paid. Thank you for your letter. If you have additional questions, please feel free to contact Secure Horizons Service Center at 800/7714347. Sincerely, Gena Rodish Precertification Specialist III c: Melissa Devalon, M.D. PacifiCare(k) July 20, 1998 Regarding Member4 ID number: Regarding request for: Date of Service: Dear Mr dental service coverage PacifiCare of Colorado 5725 Mark Dabling Boulevard Colorado Springs, Colorado 80919 Tel 719-522-6000 This is in response to the appeal regarding coverage of dental services. This is not a PacifiCare covered benefit. Therefore, it is PacifiCare's decision to uphold the denial. If you disagree with the decision, you may pursue the next level of appeal by sending a letter to: PacifiCare MEMBER APPEALS DEPARTMENT P.O. Box 6770 Englewood, Colorado 80155 Information MUST be submitted in writing in order to be considered. The specific instructions related to the formal member appeal process are outlined in the Rights and Responsibilities.�hapter of your PacifiCare Evidence of Coverage and Owner's Manual. Additional quesdion's regarding this process can be directed to Customer Services at 800/877-9777. Sincerely, r*fA Wk--" Gena Rodish Precertification Specialist III c: Barry Harry A. Burnett, M.D. `wu NCQA 0, 9/97 - 7/99 No Text No Text Appendix A Colorado Health Plan Description Form PacifiCare Health Plan Administrators, Inc. Name of Carrier City of Fort Collins PPO Plan #1 Name of Plan The format of this document is based on a format mandated for commercial plans by the State of Colorado. PART A: TYPE OF COVERAGE 1. TYPE OF PLAN Self -Funded PPO plan. 2. OUT -OF -NETWORK Yes, but member pays more for out -of -network care. CARE COVERED?' 3. AREAS OF COLORADO Plan is available only in the following counties: Adams, Arapahoe, Baca, Bent, WHERE PLAN IS Boulder, Cheyenne, Clear Creek, Crowley, Custer, Delta, Denver, Dolores, AVAILABLE Douglas, El Paso, Elbert, Fremont, Garfield, Gilpin, Grand, Huerfano, Jefferson, Kiowa, Kit Carson, Lake, Larimer, Las Animas, Lincoln, Logan, Mesa, Montezuma, Morgan, Otero, Ouray, Park, Phillips, Prowers, Pueblo, Rio Blanco, Routt, Sedgwick, Summit, Teller, Washington, Weld, Yuma. PART B: SUMMARY OF BENEFITS Important Note: This form is not a contract. It is only a summary. The contents of this form are subject to the provisions of the plan booklet, which contains all terms, covenants and conditions of coverage. Your plan may exclude coverage for certain treatments, diagnoses, or services not noted below. The benefits shown in this summary may only be available if required plan procedures are followed (e.g., plans may require prior authorization, a referral from your primary care physician, or use of specified providers or facilities). Consult the actual plan booklet to determine the exact terms and conditions of coverage. Ask your plan administrator for a copy. IN -NETWORK OUT -OF -NETWORK 4. ANNUAL DEDUCTIBLE Deductible applies unless otherwise Deductible applies unless noted. otherwise noted. a) Individual $200 $200 b) Family $600 $600 5. ENROLLEE OUT-OF-POCKET The out-of-pocket maximums exclude The out-of-pocket ANNUAL MAXIMUM2 deductibles and copayments. maximums exclude deductibles and copayments. a) Individual $500 $1,500 maximum b) Family $1,000 $3,000 maximum These maximums could be up to $2,500 individual and $5,000 family when certain benefits are paid at 50%. ' "Network" refers to a specified group of physicians, hospitals, medical clinics and other healthcare providers that your plan may require you to use in order for you to get any coverage at all under the plan, or that the plan may encourage you to use because it pays more of your bill if you use their network providers (i.e., go in -network) than if you don't (i.e., go out -of -network). 2 Out-of-pocket maximum. The maximum amount you will have to pay for allowable covered expenses under a health plan, which may or may not include the deductible or copayments, depending on the contract for that plan. IN -NETWORK OUT -OF -NETWORK 6. LIFETIME OR BENEFIT MAXIMUM $2,000,000 maximum applies to in- $2,000,000 maximum applies to PAID BY THE PLAN FOR ALL CARE and out -of -network combined. $1,000 in- andout-of-network maximum for charges related to combined $1,000 maximum Temporomandibular Joint Disorder for charges related to (TMJ). Temporomandibular Joint Disorder (TMJ). 7. COVERED PROVIDERS $3,400 physicians and 58 hospitals in All providers licensed or Colorado. See provider directory for certified to provide covered complete list. benefits. 8. ROUTINE MEDICAL OFFICE VISITS $10 copayment per visit. 70% 9. PREVENTIVE CARE a) Children's services $10 copayment per visit. Well- Well-baby/Well-child care up baby/Well-child care up to age 13. to age 13, no deductible 70%. b) Adults' services $10 copayment per visit; up to $150 in Not covered. any 12 month period for individuals age 13 and older. 10. MATERNITY a) Prenatal care $10 copayment per pregnancy. 70% b) Delivery & inpatient well baby care 90% when preauthorization is 70% when preauthorization is obtained, $250 additional deductible obtained, $250 additional when not preauthorized. deductible when not preauthorized. 11. PRESCRIPTION DRUGS $5 for generic, $10 for brand -name. 70%. Quantity not in excess of Level of coverage and restrictions on Quantity not in excess of a 34 day supply. a 34 day supply. A 90-day prescriptions A 90-day supply of maintenance supply of maintenance medications are available through a mail- medications are available order prescription pharmacy. One through a mail-order copayment for each 30-day supply up to a prescription pharmacy. One maximum of two copayments apply to copayment for each 30-day maintenance medications obtained supply up to a maximum of two through mail-order. Prepackaged units copayments apply to main - dispensed through a mail-order tenance medications obtained prescription pharmacy will have two through mail-order. copayments apply for up to three pre- Prepackaged units dispensed packaged units. For more information on through a mail-order pre - the mail-order prescription drug program, scription pharmacy will have or for information on drugs on our two copayments apply for up to approved list, call Customer Service at 1- three pre -packaged units. For 800-255-1180. more information on the mail- order prescription drug program, or for information on drugs on our approved list, call Customer Service at 1-800-255- 1180. 12. INPATIENT HOSPITAL 90% when preauthorization is obtained, 70% when preauthorization is $250 additional deductible when not obtained, $250 additional preauthorized. deductible when not preauthorized. 13. OUTPATIENT/AMBULATORY 90% when preauthorization is obtained, 70% when preauthorization SURGERY $250 additional deductible when not is obtained, $250 additional preauthorized. deductible when not preauthorized. 14. LABORATORY & X-RAY 90% 70% IN -NETWORK OUT -OF -NETWORK 15. EMERGENCY CARE' Emergency room setting inside 80% the service area: $50 copayment per visit. Copayment waived if admitted to the hospital. 16. AMBULANCE 90% 80% 17. URGENT, NON -ROUTINE, $10 copayment per visit. 70% AFTER HOURS CARE 18. BIOLOGICALLY -BASED Coverage is no less extensive Coverage is no less extensive than the MENTAL ILLNESS° CARE than the coverage provided for coverage provided for any other any other physical illness. physical illness. 19. OTHER MENTAL HEALTHCARE a) Inpatient care 90%; coverage for maximum of 70% facility charges, 50% doctor's 45 full or 90 partial days per charges; coverage for maximum of 45 full calendar year. or 90 partial days per calendar year. b) Outpatient care $10 copayment per visit; 50%; limited to 20 visits per calendar limited to 20 visits per calendar year. year. 20. ALCOHOL & SUBSTANCE Inpatient: 90%; Doctor's Inpatient: 70% for facility charges; 50% ABUSE charges are limited to $1,000 for doctor charges (doctor's charges are per calendar year for limited to $1,000 per calendar year for alcoholism and substance abuse alcoholism and substance abuse combined; coverage for combined); coverage for maximum of maximum of 45 full or 90 45 full or 90 partial days per calendar partial days per calendar year year for mental health, substance abuse for mental health, substance and alcoholism combined. abuse and alcoholism Outpatient: 50%; limited to $1,000 per combined. calendar year. Outpatient: $10 copayment per visit; limited to $1,000 per calendar year. 21. PHYSICAL, OCCUPATIONAL, & $10 copayment per visit, 70% up to $2,000 per calendar year for SPEECH THERAPY limited to $2,000 per calendar in- and out -of -network charges year for in- and out -of -network combined (including biofeedback charges combined (including therapy). biofeedback therapy). 22. DURABLE MEDICAL 90%; see plan booklet for types 70%; see plan booklet for types and EQUIPMENT and circumstances of coverage. circumstances of coverage. 23. OXYGEN 90%; covered as durable 70%; covered as durable medical medical equipment (see #22). equipment (see #22). 24. ORGAN TRANSPLANTS Cornea, heart, heart/lung Cornea, heart, heart/lung (combined), (combined), kidney, kidney, kidney/pancreas (combined), kidney/pancreas (combined), bone marrow (for certain conditions), bone marrow (for certain heart valve replacements, liver, artery or conditions), heart valve vein transplants, and breast cancer in replacements, liver, artery or stages 2 or 3 are covered according to vein transplants, and breast criteria. cancer in stages 2 or 3 are covered according to criteria. ' "Emergency care" means services delivered by an emergency care facility which are necessary to screen and stabilize a covered person. The plan must cover this care if a prudent lay person having average knowledge of health services and medicine and acting reasonably would have believed that an emergency medical condition or life or limb threatening emergency existed. d `Biologically based mental illnesses" means schizophrenia, schizoaffective disorder, bipolar affective disorder, major depressive disorder, specific obsessive -compulsive disorder, and panic disorder. 10. When a claim is submitted for payment, please check below how the following procedures are addressed: Function Automated Manual Claim inventory✓ Eligibility of employee Eligibility of dependent Unusual, customary, reasonable Benefit plan excluded charges Pre-existing condition ✓ (PPO only) Adjudication Coordination of benefits Check issuance Subrogation Explanation of benefits issuance UR authorized inpatient days Medical necessity Deductible Out-of-pocket benefit maximums Coinsurance Duplicate charges Second opinion program Coss Preferredprovider/non preferred provider Unbundling of charges Workers compensation 11. How do you propose to collect claims data from the prior third party administrator to accommodate a smooth transition? PacifiCare already administers the EPO and POS. For the PPO, the insured must submit an explanation of benefits from the prior carrier for PacifiCare to collect claims data. 21 IN -NETWORK OUT -OF -NETWORK 25. HOME HEALTH CARE 90% up to 60 visits per calendar 70% up to 60 visits per calendar year. year. 26. HOSPICE CARE 90% up to 365 days per lifetime. 70% up to 365 days per lifetime. 27. SKILLED NURSING FACILITY 90% up to 90 days per calendar 70% up to 90 days per calendar year CARE year when preauthorized; $250 when preauthorized; $250 additional additional deductible when not deductible when not preauthorized. preauthorized. 28. DENTAL CARE Available as a separate dental Available as a separate dental care care plan or as an optional plan or as an optional benefit. benefit. 29. VISION CARE Available as a separate vision Available as a separate vision care care plan or as an optional plan or as an optional benefit. benefit. 30. CHIROPRACTIC CARE $10 copayment; limited to $10 70%; limited to $10 payment per visit, payment per visit, 50 visits per limited to 50 visits per calendar year. calendar year. 31. SIGNIFICANT ADDITIONAL Routine mammograms - no Routine mammograms - no deductible COVERED SERVICES (list up to 5) deductible 100%, prostate cancer 100%, prostate cancer screening - no screening - no deductible 100%, deductible 100%, Preventive Child Health Preventive Child Health Supervision Services - no deductible 70%, Supervision Services - $10 infertility evaluation - 70%; see plan copayment, infertility evaluation - booklet for limitations on all of these $10 copayment; see plan booklet services. for limitations on all of these services. PART C: LIMITATIONS AND EXCLUSIONS 32. PERIOD DURING WHICH PRE-EXISTING 6 months for all pre-existing conditions. See plan CONDITIONS ARE NOT COVERED.5 booklet for details. 33. EXCLUSIONARY RIDERS. Can an individual's specific, No. pre-existing condition be entirely excluded from the policy? 34. HOW DOES THE POLICY DEFINE A "PRE-EXISTING A pre-existing condition is a condition for which CONDITION"? medical advice, diagnosis, care, or treatment was recommended or received within the last 3 months immediately preceding the date of enrollment or, if earlier, the fast day of the waiting period; except that pre-existing condition exclusions may not be imposed on a newly adopted child, a child placed for adoption, a newborn, other special enrollees, or for pregnancy. 35. WHAT TREATMENTS AND CONDITIONS ARE Exclusions vary by policy. A list of exclusions is EXCLUDED UNDER THIS POLICY? available immediately upon request from your carrier, agent, or plan sponsor (e.g., employer). It is important to review them to see if a service or treatment you may need is excluded from the policy. ' Waiver of pre-existing condition exclusions. State law requires carriers to waive some or all of the pre-existing condition exclusion period based on other coverage you recently may have had. Ask your carrier or plan sponsor (e.g., employer) for details. PART D: USING THE PLAN IN -NETWORK OUT -OF -NETWORK 36. Does the enrollee have to obtain a referral and/or prior No. No. authorization for specialty care in most or all cases? 37. Is prior authorization required for surgical procedures and Yes. Yes. hospital care (except in an emergency)? 38. If the provider charges more for a covered service than the No. Yes. plan normally pays, does the enrollee have to pay the difference? 39. With respect to network plans, are all the providers listed in Yes. Yes. Question 7 of this form accessible to me through my primary care physician? 40. What is the main customer service number? (800) 255-1180 41. Whom do I write/call if I have a complaint or want to file a Write to: PacifiCare PPO/Indemnity Appeals grievance? Dept., 6455 S. Yosemite St., Englewood, CO 80111 42. Whom do I contact if I am not satisfied with the resolution of Write to: Colorado Division of Insurance, ICARE my complaint or grievance? Section, 1560 Broadway, Suite 850, Denver, CO 80202 43. To assist in filing a grievance, indicate the form number of this Policy Form 12345, Group -all sizes. policy; whether it is individual, small group, or large group; and if it is a short-term policy. PART E: HOW PHYSICIANS ARE PAID. This section contains summary information about physician reimbursement. To find out how a particular provider is paid under this plan, ask that provider. IN -NETWORK OUT -OF -NETWORK 44. What are the three most frequently used methods 99% Fee -for -service (provider 100% Fee -for -service of payment for primary care physicians? Indicate is paid each time he/she treats (provider is paid each time the approximate percentage of physicians paid you). 1% Per case. he/she treats you). using each of the identified methods. 45. What are the three most frequently used methods 99% Fee -for -service (provider 100% Fee -for -service of payment for physician specialists? Indicate the is paid each time he/she treats (provider is paid each time approximate percentage of specialists paid using you). 1 % Per case. he/she treats you). each of the identified methods. 46. What other financial incentives determine No additional provider No additional provider physician payment? financial incenthes. financial incentives. An Access Plan detailing the managed care network is available upon request. Please call Customer Service at (800) 255-1180 for more information. Appendix A Colorado Health Plan Description Form PacifiCare Health Plan Administrators, Inc. Name of Carrier City of Fort Collins PPO Plan #9 Name of Plan The format of this document is based on a format mandated for commercial plans by the State of Colorado. PART A: TYPE OF COVERAGE 1. TYPE OF PLAN Self -Funded PPO plan. 2. OUT -OF -NETWORK Yes, but member pays more for out -of -network care. CARE COVERED?' 3. AREAS OF COLORADO Plan is available only in the following counties: Adams, Arapahoe, Baca, Bent, WHERE PLAN IS Boulder, Cheyenne, Clear Creek, Crowley, Custer, Delta, Denver, Dolores, AVAILABLE Douglas, El Paso, Elbert, Fremont, Garfield, Gilpin, Grand, Huerfano, Jefferson, Kiowa, Kit Carson, Lake, Larimer, Las Animas, Lincoln, Logan, Mesa, Montezuma, Morgan, Otero, Ouray, Park, Phillips, Prowers, Pueblo, Rio Blanco, Routt, Sedgwick, Summit, Teller, Washington, Weld, Yuma. PART B: SUMMARY OF BENEFITS Important Note: This form is not a contract. It is only a summary. The contents of this form are subject to the provisions of the plan booklet, which contains all terms, covenants and conditions of coverage. Your plan may exclude coverage for certain treatments, diagnoses, or services not noted below. The benefits shown in this summary may only be available if required plan procedures are followed (e.g., plans may require prior authorization, a referral from your primary care physician, or use of specified providers or facilities). Consult the actual plan booklet to determine the exact terms and conditions of coverage. Ask your plan administrator for a copy. IN -NETWORK OUT -OF -NETWORK 4. ANNUAL DEDUCTIBLE Deductible applies unless otherwise Deductible applies unless noted. otherwise noted. a) Individual $500 $500 b) Family $1,500 $1,500 5. ENROLLEE OUT-OF-POCKET The out-of-pocket maximums exclude The out-of-pocket ANNUAL MAXIMUM` deductibles and copayments. maximums exclude deductibles and copayments. a) Individual $1,000 $3,000 maximum b) Family $2,000 $6,000 maximum These maximums could be up to $5,000 individual and $10,000 family when certain benefits are paid at 50%. ' "Network" refers to a specified group of physicians, hospitals, medical clinics and other health care providers that your plan may require you to use in order for you to get any coverage at all under the plan, or that the plan may encourage you to use because it pays more of your bill if you use their network providers (i.e., go in -network) than if you don't (i.e., go out -of -network). z Out-of-pocket maximum. The maximum amount you will have to pay for allowable covered expenses under a health plan, which may or may not include the deductible or copayments, depending on the contract for that plan. IN -NETWORK OUT -OF -NETWORK 6. LIFETIME OR BENEFIT MAXIMUM $2,000,000 maximum applies to in- $2,000,000 maximum applies to PAID BY THE PLAN FOR ALL CARE and out -of -network combined. $1,000 in- and out -of -network maximum for charges related to combined $1,000 maximum Temporomandibular Joint Disorder for charges related to (TMJ). Temporomandibular Joint Disorder (TMJ). 7. COVERED PROVIDERS $3,400 physicians and 58 hospitals in All providers licensed or Colorado. See provider directory for certified to provide covered complete list. benefits. 8. ROUTINE MEDICAL OFFICE VISITS $20 copayment per visit. 70% 9. PREVENTIVE CARE a) Children's services $20 copayment per visit. Well- Well-baby/Well-child care up baby/Well-child care up to age 13. to age 13, no deductible 70%. b) Adults' services $20 copayment per visit; up to $150 in Not covered. any 12 month period for individuals age 13 and older. 10. MATERNITY a) Prenatal care $20 copayment per pregnancy. 70% b) Delivery & inpatient well baby care 90% when preauthorization is 70% when preauthorization is obtained, $250 additional deductible obtained, $250 additional when not preauthorized. deductible when not preauthorized. 11. PRESCRIPTION DRUGS $5 for generic, $10 for brand -name. 70%. Quantity not in excess of Level of coverage and restrictions on Quantity not in excess of a 34 day supply. a 34 day supply. A 90-day prescriptions A 90-day supply of maintenance supply of maintenance medications are available through a mail- medications are available order prescription pharmacy. One through a mail-order copayment for each 30-day supply up to a prescription pharmacy. One maximum of two copayments apply to copayment for each 30-day maintenance medications obtained supply up to a maximum of two through mail-order. Prepackaged units copayments apply to main - dispensed through a mail-order tenance medications obtained prescription pharmacy will have two through mail-order. copayments apply for up to three pre- Prepackaged units dispensed packaged units. For more information on through a mail-order pre - the mail-order prescription drug program, scription pharmacy will have or for information on drugs on our two copayments apply for up to approved list, call Customer Service at 1- three pre -packaged units. For 800-255-1180. more information on the mail- order prescription drug program, or for information on drugs on our approved list, call Customer Service at 1-800-255- 1180. 12. INPATIENT HOSPITAL 90% when preauthorization is obtained, 70% when preauthorization is $250 additional deductible when not obtained, $250 additional preauthorized. deductible when not preauthorized. 13. OUTPATIENT/AMBULATORY 90% when preauthorization is obtained, 70% when preauthorization SURGERY $250 additional deductible when not is obtained, $250 additional preauthorized. deductible when not preauthorized. 14. LABORATORY & X-RAY 90% 70% IN -NETWORK OUT -OF -NETWORK 15. EMERGENCY CARE Emergency room setting inside 80% the service area: $50 copayment per visit. Copayment waived if admitted to the hospital. 16. AMBULANCE 90% 80% 17. URGENT, NON -ROUTINE, $20 copayment per visit. 70% AFTER HOURS CARE 18. BIOLOGICALLY -BASED Coverage is no less extensive Coverage is no less extensive than the MENTAL ILLNESS° CARE than the coverage provided for coverage provided for any other any other physical illness. physical illness. 19. OTHER MENTAL HEALTHCARE a) Inpatient care 90%; coverage for maximum of 70% facility charges, 50% doctor's 45 full or 90 partial days per charges; coverage for maximum of 45 full calendar year. or 90 partial days per calendar year. b) Outpatient care $20 copayment per visit; 50%; limited to 20 visits per calendar limited to 20 visits per calendar year. year. 20. ALCOHOL & SUBSTANCE Inpatient: 90%; Doctor's Inpatient: 70% for facility charges; 50% ABUSE charges are limited to $1,000 for doctor charges (doctor's charges are per calendar year for limited to $1,000 per calendar year for alcoholism and substance abuse alcoholism and substance abuse combined; coverage for combined); coverage for maximum of maximum of 45 full or 90 45 full or 90 partial days per calendar partial days per calendar year year for mental health, substance abuse for mental health, substance and alcoholism combined. abuse and alcoholism Outpatient: 50%; limited to $1,000 per combined. calendar year. Outpatient: $20 copayment per visit; limited to $1,000 per calendar year. 21. PHYSICAL, OCCUPATIONAL, & $20 copayment per visit, 70% up to $2,000 per calendar year for SPEECH THERAPY limited to $2,000 per calendar in- and out -of -network charges year for in- and out -of -network combined (including biofeedback charges combined (including therapy). biofeedback therapy). 22. DURABLE MEDICAL 90%; see plan booklet for types 70%; see plan booklet for types and EQUIPMENT and circumstances of coverage. circumstances of coverage. 23. OXYGEN 90%; covered as durable 70%; covered as durable medical medical equipment (see #22). equipment (see 422). 24. ORGAN TRANSPLANTS Cornea, heart, heart/lung Cornea, heart, heart/lung (combined), (combined), kidney, kidney, kidney/pancreas (combined), kidney/pancreas (combined), bone marrow (for certain conditions), bone marrow (for certain heart valve replacements, liver, artery or conditions), heart valve vein transplants, and breast cancer in replacements, liver, artery or stages 2 or 3 are covered according to vein transplants, and breast criteria. cancer in stages 2 or 3 are covered according to criteria. 3 "Emergency care" means services delivered by an emergency care facility which are necessary to screen and stabilize a covered person. The plan must cover this care if a prudent lay person having average knowledge of health services and medicine and acting reasonably would have believed that an emergency medical condition or life or limb threatening emergency existed. A `Biologically based mental illnesses" means schizophrenia, schizoaffective disorder, bipolar affective disorder, major depressive disorder, specific obsessive -compulsive disorder, and panic disorder. IN -NETWORK OUT -OF -NETWORK 25. HOME HEALTH CARE 90% up to 60 visits per calendar 70% up to 60 visits per calendar year. year. 26. HOSPICE CARE 90% up to 365 days per lifetime. 70% up to 365 days per lifetime. 27. SKILLED NURSING FACILITY 90% up to 90 days per calendar 70% up to 90 days per calendar year CARE year when preauthorized; $250 when preauthorized; $250 additional additional deductible when not deductible when not preauthorized. preauthorized. 28. DENTAL CARE Available as a separate dental Available as a separate dental care care plan or as an optional plan or as an optional benefit. benefit. 29. VISION CARE Available as a separate vision Available as a separate vision care care plan or as an optional plan or as an optional benefit. benefit. 30. CHIROPRACTIC CARE S20 copayment; limited to $10 70%; limited to $10 payment per visit, payment per visit, 50 visits per limited to 50 visits per calendar year. calendar year. 31. SIGNIFICANT ADDITIONAL Routine mammograms - no Routine mammograms - no deductible COVERED SERVICES (list up to 5) deductible 100%, prostate cancer 100%, prostate cancer screening - no screening -no deductible 100%, deductible 100%, Preventive Child Health Preventive Child Health Supervision Services - no deductible 70%, Supervision Services - $20 infertility evaluation - 70%; see plan copayment, infertility evaluation - booklet for limitations on all of these $20 copayment; see plan booklet services. for limitations on all of these services. PART C: LIMITATIONS AND EXCLUSIONS 32. PERIOD DURING WHICH PRE-EXISTING 6 months for all pre-existing conditions. See plan CONDITIONS ARE NOT COVERED.S booklet for details. 33. EXCLUSIONARY RIDERS. Can an individual's specific, No. pre-existing condition be entirely excluded from the policy? 34. HOW DOES THE POLICY DEFINE A "PRE-EXISTING A pre-existing condition is a condition for which CONDITION"? medical advice, diagnosis, care, or treatment was recommended or received within the last 3 months immediately preceding the date of enrollment or, if earlier, the first day of the waiting period; except that pre-existing condition exclusions may not be imposed on a newly adopted child, a child placed for adoption, a newborn, other special enrollees, or for pregnancy. 35. WHAT TREATMENTS AND CONDITIONS ARE Exclusions vary by policy. A list of exclusions is EXCLUDED UNDER THIS POLICY? available immediately upon request from your carrier, agent, or plan sponsor (e.g., employer). It is important to review them to see if a service or treatment you may need is excluded from the policy. ' Waiver of pre-existing condition exclusions. State law requires carriers to waive some or all of the pre-existing condition exclusion period based on other coverage you recently may have had. Ask your carrier or plan sponsor (e.g., employer) for details. PART D: USING THE PLAN IN -NETWORK OUT -OF -NETWORK 36. Does the enrollee have to obtain a referral and/or prior No. No. authorization for specialty care in most or all cases? 37. Is prior authorization required for surgical procedures and Yes. Yes. hospital care (except in an emergency)? 38. If the provider charges more for a covered service than the No. Yes. plan normally pays, does the enrollee have to pay the difference? 39. With respect to network plans, are all the providers listed in Yes. Yes. Question 7 of this form accessible to me through my primary care physician? 40. What is the main customer service number? (800) 255-1180 41. Whom do I write/call if I have a complaint or want to file a Write to: PacifiCare PPO/Indemnity Appeals grievance? Dept., 6455 S. Yosemite St., Englewood, CO 80111 42. Whom do I contact if I am not satisfied with the resolution of Write to: Colorado Division of Insurance, ICARE my complaint or grievance? Section, 1560 Broadway, Suite 850, Denver, CO 80202 43. To assist in filing a grievance, indicate the form number of this Policy Form 12345, Group -all sizes. policy; whether it is individual, small group, or large group; and if it is a short-term policy. PART E: HOW PHYSICIANS ARE PAID. This section contains summary information about physician reimbursement. To find out how a particular provider is paid under this plan, ask that provider. IN -NETWORK OUT -OF -NETWORK 44. What are the three most frequently used methods 99% Fee -for -service (provider 100% Fee -for -service of payment for primary care physicians? Indicate is paid each time he/she treats (provider is paid each time the approximate percentage of physicians paid you). 1% Per case. he/she treats you). using each of the identified methods. 45. What are the three most frequently used methods 99% Fee -for -service (provider 100% Fee -for -service of payment for physician specialists? Indicate the is paid each time he/she treats (provider is paid each time approximate percentage of specialists paid using you). 1% Per case. he/she treats you). each of the identified methods. 46. What other financial incentives determine No additional provider No additional provider physician payment? I financial incentives. I financial incentives. An Access Plan detailing the managed care network is available upon request. Please call Customer Service at (800) 255-1180 for more information. SECTION 2 - BENEFIT EXCLUSIONS AND LIMITATIONS A. THE FOLLOWING EXCLUSIONS AND LIMITATIONS APPLY TO ALL BENEFITS: All services for a surrogate mother who is not an Insured Individual are not covered. 2. Any accidental bodily injury which arises out of or in the course of any employment with any employer, including self-employed individuals, or for which the individual is entitled to benefits under any worker's compensation law or occupational disease law, or receives any settlement from a worker's compensation carrier, unless it is shown in the Schedule of Benefits that the insurance provided by a benefit is issued on both an occupational and non -occupational basis. 3. Any illness for which the individual is entitled to benefits under any worker's compensation or occupational disease law, or receives any settlement from a worker's compensation carrier. 4. Charges due to a pre-existing illness or condition, except as shown in the Schedule of Benefits. 5. Charges due to tissue transplants, organ transplants or replacement of tissue or organs, whether natural or artificial replacement materials or devices are used; and all charges due to complications arising from such procedures or treatment unless such charges are specifically provided for on the Schedule of Benefits. 6. Charges for any treatment for cosmetic purposes or for cosmetic surgery, including aging of the skin, hair loss, or excess hair. Except for cosmetic treatment or surgery: a. due solely to an accidental bodily injury which occurred while the individual was insured under this Policy; or b. for the reconstructive surgery and prosthetic devices following mastectomy for breast cancer; c. due solely to a birth defect of an individual who was insured under this Policy on the date of his or her birth. 7. Charges for cognitive therapy, by any name called. Charges for custodial, domiciliary, convalescent, and/or intermediate care, including rest cures (collectively "custodial care"), whether furnished in the home or in an institution, including a nursing home or similar facility. See the definition of "custodial care" in the Definition Section, Section 7. 9. Charges for dental services or supplies for treatment of the teeth, gums or alveolar processes. Except for hospital charges if the Insured Individual is a bed patient and the admission is necessary for a medical reason as authorized and pre -certified and except for any dental charges covered under the Major Medical. 10. Charges for diagnosis or treatment of temporomandibular joint dysfunction, by any name called. EXCEPT, this limitation does not apply to such charges which result in payments not exceeding a total of $1,000.00 while insured, subject to the Deductible and benefit percentage shown on the Schedule of Benefits. 11. Charges for donor semen for artificial insemination, in vitro fertilization, in vivo fertilization, embryo transport procedures, surrogate parenting, injectable substances, medications used to correct physiological abnormalities or to stimulate the individual's natural reproductive system, supplies, procedures and all other associated expenses related to infertility. 12. Charges for eye glasses or contact lenses or the fitting of them, if Vision Benefits are not included in this policy. Except as specified under Major Medical Benefits for cataract surgery. 13. Charges for medical and related services including but not limited to, drugs, biological products, devices and medical, surgical and diagnostic services which are determined by TakeCare to be experimental or investigational. Drugs, biological products and devices are considered experimental or investigational if: a. they have not received final approval from the appropriate government regulatory bodies, including the FDA; or b. their use for the particular illness or injury being treated is not accepted as the standard of medical practice in the community; or c. drugs and biological products, when prescribed for experimental or non -FDA approved indications, unless listed as a specific indication in the Drug Information for the Health Care Professional, published by the United States Pharmacopeial Convention or in the American Hospital Formulary Services edition of Drug Information. TakeCare considers any health care service, including organ and tissue transplants, to be experimental or investigational, unless all of the following criteria are met: a. the health care services are accepted in the appropriate medical community in which the treatment is rendered as standard, safe, effective, and non -experimental or non -investigational for the illness or injury being treated; b. the health care services are attainable outside of a research institution or research program for the illness or injury being treated; c. based on credible and accepted medical evidence, the health care services clearly improve the net health outcomes as evaluated against alternative non -experimental or non -investigational health care services for the illness or injury being treated. 14. Charges for medical supplies unless provided elsewhere in this Policy. 15. Charges for non-prescription drugs; vitamins, nutrients and food supplements - even if prescribed or administered by a Doctor. This does not apply to the extent any of these is the only available source of nutrients. 16. Charges for nutritional counseling, educational services or food supplements. 17. Charges for penile prostheses are not covered unless in treatment of a documented non -psychiatric organic condition. 18. Charges for private duty nursing. 19. Charges for professional services for treatment which involves manual manipulation (with or without the application of treatment modalities such as, but not limited to diathermy, ultrasound, heat and cold) of the spinal skeletal system and/or surrounding tissue to restore proper articulation of joints, alignment of bones or nerve functions which are in excess of: a. a payment of $10.00 for each visit; b. one visit on any one day; or c. 50 visits during anyone Calendar Year. Except that, this limitation does not apply if such services are rendered: a. during general anesthesia; b. during a cutting operation; or c. while the patient is confined in a hospital. 20. Charges for services of a person who usually lives in the same household as the Insured Individual, or who is a member of his or her immediate family or the family of his or her spouse. 21. Charges for services or supplies furnished by an agency of the United States Government or a foreign government or agency, unless excluding them is prohibited by law. 22. Charges for smoking cessation programs for treatment of nicotine or tobacco use, including nicotine gum and patches. 23. Charges for support garments; disposable medical supplies used at home: devices used at home to perform tests on body substances. Except that insurance is provided for test strips and glucometers used by diabetics and subject to Deductible and benefit percentage shown in the Schedule of Benefits. 24. Charges for the purchase or repair of hearing aids, if Hearing Aid Benefits are not included in this policy. 25. Charges for the treatment of refractive errors, including but not limited to, eye exams and radial keratotomy procedures. 26. Charges for treatment by a doctor which is not within the scope of his or her license. 27. Charges for vision therapy by any name called. 28. Charges for vocational rehabilitation, by any name called. 29. Charges for which benefits are not provided in this policy. 30. Charges incurred for the reversal of sterilization. 31. Charges incurred or disability claimed while an Insured Individual is not under the direct care of a doctor. 32. Charges related to changing the sex of an individual. 33. Charges which are in excess of the reasonable and customary charges for services and materials. 34. Charges which are not medically necessary to the care or treatment of an illness or injury except as described elsewhere in this Policy. Charges which the Insured Individual is not legally obliged to pay. 36. Charges which would not have been made if no insurance existed. 37. Contraceptive devices and implants. This includes oral contraceptives unless listed as a Covered Charge under the Prescription Drug Benefit. 38. Losses which are due to war or any act of war, whether declared or undeclared. 39. Surgery for morbid obesity, unless medically necessary and appropriate treatment measures have failed for reasons other than compliance of the Insured Individual. 40. The rental or purchase of aids, including but not limited to, ramps, elevators, stair lifts, swimming pools, air filtering systems, environmental control equipment, spas, hot tubs, or automobile hand controls, or any modification made to dwellings, property or motor vehicles. 41. To the extent that a natural disaster, war, riot, civil insurrection, epidemic, labor dispute not involving the Policy, or that other similar circumstances not within the control of the Policy results in the facilities, personnel or financial resources of the Policy being unavailable to arrange for the provisions of benefits under the Policy, the Policy's obligation to provide such services or benefits will be limited to the requirement that TakeCare make a good faith effort to provide or arrange for the provision of such services or benefits within the resulting limitations on the availability of its facilities, personnel or resources, and the Policy will have no liability or obligation as a result of any delay or failure to provide services or benefits under the Policy. 02/98 12. Present an implementation plan to begin adjudicating claims January 1, 1999 assuming a September 1, 1998 notification. Completion Date ImplementationResponsibility Insurance Committee Decision City of Fort Collins October 9, 1998 - Development of Open Enrollment Chris Lawrence October 13, 1998 Materials Assessment of Customized Needs Schedule Open Enrollment Late October, 1998 Open Enrollment Meetings Chris Lawrence December 7, 1998 Receipt of Enrollment Forms, Chris Lawrence December 21, 1998 Completed Summary Plan Documents Chris Lawrence December 7, 1998 - Enter Enrollment Data Jeff Green December 11, 1998 December 18, 1998 1 Mail ID Cards Scott Lane Benefit literature and other communication materials will be available in draft form 30 days after receipt of enrollment forms. 13. In the event of termination, what is your guaranteed fee to provide for payment of run -out claims? Include all data processing charges. Service fee in place immediately proceeding termination multiplied by final enrollment multiplied by number of months services are requested (usually three months). 14. What mechanisms are in place for claims administration backup? Are you proposing a dedicated claims administration unit and 800 number for the City? The claims department has fully trained backup processors for all positions. Processors are fully trained and able to handle claims administration for all clients. 15. Are you able to administer on-line, electronic transfer, and tape -to -tape eligibility transfers? How does this impact your cost proposal? PacifiCare does offer Electronic Data Interface (EDI) capabilities to employers utilizing ANSI X-12 national standards. Those employers unable to comply with ANSI X-12 standards may instead submit eligibility by one of the following methods: ♦ The first ability to accept eligibility data is via our ILIAD proprietary format. If an employer group prefers to provide data in their proprietary format or would like to submit data via the ANSI standard format, a service request would need to be generated for development. Turnaround times for this process are dependent on how clean the data is when received into PacifiCare. Average time is usually 2-3 weeks. ♦ The second is via magnetic media. PacifiCare will load the data and produce reports that expedite manual entry of the data. Turnaround times for this format are not currently available. They are dependent on the Service Request prioritization and development scheduling process. 22 No Text Sample Performance Standards - PacifiCare of Colorado Category and Definition % of Timeframe of Measurement Administration Fees at Risk Proposed. 1. 85% of all clairtis will be processed within 30 The turnaround time (TAT) calendar days of receipt of a "clean claim". .25% will be tracked monthly. Following the Contract Year, PacifiCare will average the monthly results and report to The City of Fort Collins the yearly average as part of an annual year end report. Penalties will be assessed on that year end average. Proposed. 2. All claims will be processed with the accuracy The claims accuracy rates rates: .25% will be tracked monthly. Following the Contract 95% Financial Accuracy - Payment Dollars Year, PacifiCare will 95% Financial Accuracy - Payment Incidence average the monthly results 95% Administrative Accuracy and report to The City of Fort Collins the yearly Financial Accuracy - Payment Dollars is defined as average as part of an annual follows: Over payment dollars plus under year end report. Penalties payment dollars divided by total dollars will be assessed on that audited. year end average. Financial Accuracy- Payment Incidence is defined as follows: Number of claims with financial errors divided by number of claims audited. Administrative Accuracy is defined as follows: Data entry field errors or procedural errors divided by number of item/fields audited. Proposed: 3. Plan's customer service call abandonment rate The abandonment rate will will not exceed 5%. .25% be tracked monthly. Following the Contract Year, PacifiCare will average the monthly results and report to The City Of Fort Collins the yearly average as part of an annual year end report. Penalties will be assessed on that ear end avera e. Proposed: The "average speed to 4. Member calls will be answered by a "qualified answer" will be tracked person' within 50 seconds average. .25% monthly. Followin the Category and Definition % of Timeframe of Measurement Administration Fees at Risk Contract Year, PacifiCare Definitions: will average the monthly A "qualified person" is an employee who has results and report to The completed the formal training program City of Fort Collins the necessary to become an PacifiCare customer yearly average as part of an service representative. annual year end report. Penalties will be assessed on that year end average. Proposed: 5. PacifiCare will process 90% of referrals within The referral response time 48 hours of request by Primary Care Physician. .25% will be tracked monthly. Following the Contract Year, PacifiCare will average the monthly results and report to The City of Fort Collins the yearly average as part of an annual year end report. Penalties will be assessed on that year end average. Proposed: 6. PacifiCare will meet the following access On a quarterly basis a standards for medical/surgical care with a 95% .25% random sample of PCP threshold based on our established percentage offices (approximately one of compliance: quarter of the PCP network) will be surveyed regarding Emergency......................Immediately their next available Established compliance rate — 100% appointment times for Urgent Care ....................... w/i 24 hrs emergent, urgent, non - Established compliance rate — 95% urgent acute illness, chronic Nonurgent Acute Illness..... w/i 48 hrs illness and maintenance Established compliance rate — 85% visits. Results are compiled Health Maintenance Visit. w/i 45 days quarterly for our entire Established compliance rate — 85% network. PacifiCare will average the quarterly results Definitions: and report to The City of PacifiCare's access standards have been Fort Collins the yearly created in partnership with our physicians to average as part of an annual meet the health care needs of our members. year end report. Penalties will be assessed on that year end average. Proposed: 7. 95% of enrollee ID cards will be mailed within The mail time for ID cards 10 working days from the time eligibility is .25% is tracked on an ongoing received. basis. Following the Contract Year, PacifiCare will provide The City of Fort Collins the yearly average as part of an annual year Category and Definition % of Timeframe of Measurement Administration Fees at Risk end report. Penalties will be assessed on that year end average. Proposed: 8. Annual HEDIS reports on an PacifiCare Book HEDIS reports will be of Business and Client Specific basis will be .25% delivered to the The City of available by August 15'" following the Fort Collins by August 151" calendar year of the report. for the previous calendar Delivery of HEDIS will be dependent upon year. Delivery of HEDIS will be reporting requirements and data set dependent upon reporting definitions set by NCQA. requirements and data set definitions set by NCQA. HEDIS reports are only ptepared on a calendar year basis due to reporting requirements. Proposed: 9. PacifiCare will retain NCQA accreditation As pact of the year end throughout the life of the agreement with The .50% report to the City of Fort City of Fort Collins. Collins, PacifiCare will report on NCQA accreditation for the previous Contract Year. Proposed: 10. 80% of written inquiries to member services The resolution time will be will be resolved within 20 working days .25% tracked monthly. Following the Contract Year, A written inquiry is defined as an appeal PacifiCare will average the (written request by a covered person or their monthly results and report representative for reconsideration of a to The City of Fort Collins decision) or grievance (written complaint the yearly average as part of generated by a covered person or their an annual year end report. representative regarding quality of care Penalties will be assessed rendered by a Provider). on that year end average. Proposed. 11. Our risk management department will Acknowledgment time will acknowledge receipt of written inquires to .25% be tracked monthly. member services within 7 working days. Following the Contract Year, PacifiCare will A written inquiry is defined as an appeal average the monthly results (written request by a covered person or their and report to The City of representative for reconsideration of a Fort Collins the yearly decision) or grievance (written complaint average as part of an annual generated by a covered person or their year end report. Penalties Category and Definition % of Timeframe of Measurement Administration Fees at Risk representative regarding quality of care will be assessed on that rendered by a Provider). year end average. Total At Risk 3% The performance standards and penalties associated with these measurements will be assessed following the Contract Year end on a "per Performance Standard" measure. A report will be provided within 90 days of the contract year end. All measures are based on book of business results unless otherwise indicated. PacifiCare is willing to place 3% of administration fees at risk. The total administration fee portion of the premium in effect for 1998, based upon enrollment of 605 PPO, 653 EPO, and 76 POS employees, equates to $.84 per employee per month, or a maximum of $13,450 per year. Ik SAMPLE SIGNATURE PAGE It is agreed, by the signatures below, the preceding Performance Standards will become obligations of PacifiCare of Colorado, for the period January 1, 1999 through December 31, 1999, under the Contract between PacifiCare and the City of Fort Collins. Sandra Peif Date PacifiCare of Colorado Director of Sales & Service, Large Accounts CLIENT Date A No Text No Text STATF DEPARTMENT OF STATE CERTIFICATE I, VICTORIA BUCKLEY, SECRETARY OF STATE OF THE STATE OF COLOR ADO HEREBY CERTIFY THAT ACCORDING TO THE RECORDS OF THIS OFFICE PACIFICARE OF COLORADO, INC. (COLORADO INSURANCE CORPORATION) FILED ARTICLES OF INCORPORATION ON NOVETOER 8, I985. Dated: June 23, 2998 SECRETARY OF STATE PBCfCc—ffe Z�±»%Roma .�� ,.... \ Ot, < y�\ % � (' /la k °���� / apowerful driver dquality and innovation 4� \ @#ReR 2eu \ nsimply makes Rood ages e»r * 16. Do you have the capability for the City to have access to your claims and eligibility system through an on-line system? What, if any, are the additional costs? PacifiCare does not currently offer system access. 17. Does your system handle member files as opposed to subscriber files? Provide samples of "per member" utilization reports which reflect this capability. Yes, PacifiCare maintains records at the member rather than the subscriber level. Please refer to Sample Per Member Utilization Report attachment. 18. Do you have physician and patient profiling/reporting capabilities? If so, please describe the standard reports available and ad hoc capability. Provide sample reports. PacifiCare of Colorado has physician profiling capabilities. Standard patient profiling reports are not something we currently offer. Please refer to Physician Profile Sample attachment 19. How would your organization determine usual, customary and reasonable charges for medical, surgical and anesthesia procedures? Answer this question in specific detail for PPO, POS and EPO claims; and by area (Colorado, national, worldwide). How often is this data updated? Our HMO medical claims are paid based on McGraw Hill. The data is updated every six months. 20. Would you be willing to provide underwriting review for medical evidence for enrollments other than during open enrollment periods? Would there be an extra charge for this service? If so, please state your charges. This service is not available due to HIPAA legislation. 21. If claims exceed the individual attachment point, how often are updated claim reports sent to the stop -loss carrier? Explain this process of coordination with the stop loss carrier. Updated claim reports are submitted monthly. 22. Please submit a sample of your proposed claim and Explanation of Benefits forms. Would you be willing to customize the information contained in these forms? Would there be an additional cost? The standard for HCFA 1500 or UB92 are the only required forms. Customization of the EOB is not available. Industry standard forms cannot be customized. 23. Please state what records (including the participant and data processing documents) would, in fact, belong to the City upon contract termination. Upon contract termination, participant histories can be produced by the data system for The City of Fort Collins. 23 24. In the event of contract termination, when would records which are property of the Plan be released to the party or organization designated by the City? Describe your termination notice requirement. Records would be released as soon as the reports required were completed and the information was made available. 25. What non-standard claim utilization and payment reports are available? What, if any, are the additional costs? PacifiCare provides customized reports on an AdHoc basis. 26. It is required that all reporting requirements be included in your per capita administrative fee. Would you agree with this provision? PacifiCare provides a standard package of reports which is included in the administrative fees. Custom reports are available at an additional cost to the group. Requests for custom reports must be evaluated individually, as not all requests can be accommodated. Pricing for custom reports that the Plan agrees to provide will be based upon the complexity of developing the report and the frequency that it must be provided. 27. Will a representative attend and assist in open enrollment meetings? Is a representative available to meet with employees other than during open enrollment? Is there a separate charge for this service? Representatives are available at no additional cost. 28. Provide details of your company's claims dispute resolution procedures. Member Complaint and Appeal Process Member Comulaints If the member is not satisfied with services or benefits received from PaciriCare, the member is asked to contact the Customer Services Department initially and an attempt will be made to resolve concerns through an internal issue resolution process. Member Anneal Process If the member is not satisfied with the resolution and wishes to pursue the issue further, the member must submit a written request to initiate the member appeal process. Written requests should be directed to the PacifiCare Member Appeals Team. Department Review The PaciriCare Customer Service Department will attempt to resolve such written requests through research by the appropriate department to determine if criteria and processes have been administered correctly. The member will be notified of the resolution usually no later than thirty-one (31) days after PaciriCare receives the request. If the member is not satisfied with the decision, a written request must be submitted within ninety (90) days of the review determination to initiate the next level (Level not the Member Appeal Process. If the next step of the process is not initiated by the meinber as explained above, the action or claim denial will be fmal. 24 Member Relations Committee Review The Member Relations Committee will provide a formal review and respond to the member usually within thirty-one (31) days after receiving the request. If the member is not satisfied with the decision of the Member Relations Committee, the member can request a review by a Formal Member Appeals Panel if new or additional information becomes available, and a written request is submitted to PacifiCare within thirty-one (31) days of the Member Relations Committee determination. If a written request is not submitted as stated, then the action or claim denial will be final. Formal Member Appeals Panel Review Only if new or additional information becomes available, the member may submit a written request for review by a Formal Member Appeals Panel. This Panel consists of individuals and providers (both internal and external) who have knowledge of the benefit and medical areas involved in the matter and is facilitated by PacifiCare. The member is invited to meet with the Panel to present the issue. A written determination of the Panel's findings is then sent to the member usually within thirty-one (31) days of the Panel meeting. Arbitration If a member is not satisfied with the resolution of a legal claim after exhausting all levels of the formal member appeals process applicable to the claim, PacifiCare and the member agree that they shall submit the claim to binding arbitration in accordance with the Commercial Arbitration Rules of the American Arbitration Association unless both PacifiCare and the member agree in writing to use another form of alternative dispute resolution (e.g., mediation) as PacifiCare and the member may agree upon in writing. The results of the binding arbitration shall be fmal, with no further recourse in a court of law or otherwise available to either PacifiCare or the member. Judgment upon the award rendered by the arbitrator(s) shall be entered in any court having jurisdiction. PacifiCare and the member shall equally share the costs of arbitration; however, each party shall be individually responsible for the expenses related to its attorney, experts and evidence. 29. Will you agree to furnish monthly and year-to-date average enrollment, and total claims paid, by line of coverage, showing the information separately for active, COBRA participants, and retirees; and separately for employees and dependents? If self -funded, PacifiCare of Colorado will provide a Monthly Experience Summary (MES) which will provide monthly, year to date average enrollment, total claims paid by line of coverage, and will show information separately for active, COBRA, and retirees. In addition, a quarterly Sherlock report will be provided which will separate claims for employees and dependents. 30. Please describe in detail what claim reports would be provided at no cost to the City and consultant. Please describe the utilization data to be included in your reports. For example, number of hospital admissions, number of hospital days, etc. Monthly Experience Summaries and Sherlock reports are available at no cost to the City of Fort Collins or the consultant. Samples of these reports are included under the Sample Utilization Reports attachment. 25 31. Are you willing and able to provide the City or its consultant electronic claims data? What, if any, are the additional costs? PacifiCare is not currently capable of performing electronic claims data. 32. What stop -loss carriers have approved your company? Allianz Life Insurance Company of North America and Lincoln National Reinsurance Company. 33. Do your fees include the cost to produce check stock, postage, telephone service, and printing of forms? If not, what are your charges for such services? Yes, fees include the cost to produce check stock, postage, telephone service and printing of forms. 34. How often are claim reimbursement and administrative expense billings submitted? Form of transfer? Will the City collect all interest credits? Claims reimbursement billings are submitted weekly, while administrative expense billings are submitted monthly. Both are via wire transfer. 35. Describe how new members (employees) will be added to your system, terminated members inactivated and status changes made to current members. New members are processed by paper enrollment form unless other arrangements are previously agreed upon. 36. Do you agree to provide COBRA and Retiree administration? No, PacifiCare does not provide COBRA and Retiree administration. 37. In addition to COBRA, describe your support services in complying with the issuance of HIPAA certifications. Is there an additional charge for these services? These services are not available for self -funded clients. 38. What or how many hours per day will customer service representatives by available to assist callers with questions and problems? Customer Services Representatives are available from 7:00 AM - 6:00 PM Monday through Friday. 39. Describe what your coordination efforts would be in dealing with the City's utilization management and/or case management firm. PaciliCare performs all utilization management and case management functions. However, if The City of Fort Collins contracted to a third party, PacifiCare would be willing to make the appropriate altercations to coordinate these efforts. M UR SERVICES FEE QUOTATION SECTION Please provide your fee quotations to provide the cost management services requested. Your quotation should be in the following format. g e 3° PEU3 Plans Onl Monthly Ede F Eli' ble Em lox ee N Utuf. � � ` � � ixer,Case -har es 1. Pre-Admission/Concurrent Utilization Review 2. Psychiatric/Substance Abuse Review (if separate from #1 above) Full Package (1 and 2 above) 1, 2 and 3 = $ 8.18 N/A (included in TPA 3. Case Management`) Services) Other Charges 1. Start-Up/Implementation N/A Fee N/A No charge for standardmaterials. 2. Basic Communication Package (brochure, N/A stickers, and letters) Note: Excludes Medicare Retirees. (1) Indicate hourly rate if this is your standard arrangement. For purposes of your quote, please assume 600 eligibles in the PPO plans. 27 UR SERVICES FEE QUOTATION SECTION (continued) � 8 � r tl Y v r 5 W(41e., .F21 .. POS EPO POS EPO 1. Pre- Admission/Concurrent Utilization Review 2. Psychiatric/Substance Abuse Review (if separate from #1 above) Full Package (1 and 2 1,2 and 3 = 1,2 and 3 = N/A N/A above) $10.56 $10.45 (included in (included in 3. Case ManagemenO TPA TPA Services) Services) Other Charges 1. Start-Up/Implementation N/A N/A N/A N/A Fee 2. Basic Communication No charge No charge Package (brochure, for for N/A N/A stickers, and letters) standard standard materials materials Note: Excludes Medicare Retirees. (1) Indicate hourly rate if this is your standard arrangement. For purposes of your quote, please assume 80 eligibles in the POS plan and 585 in the EPO plan. How do the above charges differ assuming you are selected to provide utilization review for all plans? -t, No change to above charges. 28 UTILIZATION MANAGEMENT QUESTIONNAIRE NOTE: PLEASE READ QUESTIONS CAREFULLY. While some questions may allow for multiple responses, those annotated with 'CHECK ONE ONLY' MUST be answered with only ONE response option. PRESERVICE REVIEW 1. Does your firm perform preservice review (also known as precertification, prior authorization) of proposed elective health care services? (al) ❑O a. Yes ❑ b. No (Proceed to next Section) 2. Indicate which services are reviewed under your preservice review program (check all applicable to your program): (a2) ❑x a. Elective inpatient medical/surgical admissions x❑ b. Elective outpatient surgery (only predefined surgeries) ❑ c. Diagnostic services © d. Durable medical equipment 0 e. Corrective appliances/prosthetics ❑ f. Skilled nursing facility ❑K g. Home health/home enteral/parenteral therapy ❑ h. Musculoskeletal services (e.g., chiropractic) © i. Medical services (e.g., physical therapy, Dr's office visits) ❑ j. Psychiatric admissions (acute and residential) ❑ k. Psychiatric outpatient therapy services ❑ 1. Substance abuse (e.g., detoxification, rehabilitation) ❑ in. Other: 3. Precertification includes the analysis and determination of which of the following (may check more than one): (0) 1] a. Eligibility of coverage. 19 b. Appropriate use of Plan (e.g. work -related injury which is excluded from the plan). © c. Appropriate LEVEL OF CARE (e.g., inpatient versus outpatient). 19 d. Reasonable LENGTH OF STAY for inpatient confinement. © e. Actual MEDICAL NECESSITY and appropriateness of the surgery or service being requested (e.g., does service require performance). 19 f. Necessity for the services of an ASSISTANT SURGEON with each operative procedure analysis. 17 g. Necessity for a proposed PREOPERATIVE hospital day. © h. Necessity for a proposed 23 hour observation stay following outpatient surgery. ❑ i. Other: Explain 29 Pad fiCare ° July 29, 1998 Mr. James B. O'Neill II, CPPO Director of Purchasing & Risk Management The City of Fort Collins 256 West Mountain Avenue Fort Collins, CO 80521 RE: Proposal No. P-682 Dear Mr. O'Neill: PacifiCare of Colorado 6455 South Yosemite Street Englewood, Colorado 80111 Tel 303-220-5800 Thank you for the opportunity to continue providing EPO and Point of Service benefits to the City of Fort Collins, and the chance to obtain additional members through the PPO contract. We have enjoyed our long term health care partnership with the City of Fort Collins and look forward to another opportunity to offer high quality health care to your employees. Enclosed are four copies of our proposal for the following products: • PPO • Point of Service • EPO • TPA • UR • Stop Loss We will not be quoting on the carve -out prescription drugs, but did offer the benefit under our quoting of the three requested medical plans. The sample communication materials have been left out separately from the proposal binders because of their size. I have enclosed four copies each of the EPO/POS and PPO sample packets and noted the product on each packet accordingly. The following addendums were received: • Addendum No. 1, June 24, 1998 • Addendum No. 2, July 14, 1998 • Addendum No. 3, July 16, 1998 . Ea NLL .�'' >fLRF01LRlI0M '� NCQA 0, ART 9/97 - 7/99 4. Indicate the type of review information which is communicated to the claims payor by your firm: (a4) gP r �.C�Yanns payon r im Appioxate Method° of 'Notification �b a d CHECK O1�TE . CH> K ONP 41, a. Appropriate level of care a. Wes a. x❑Daily a. ❑Phone call (e.g. outpatient) b, ❑No b. ❑Weekly b. ❑Phone call plus c. ❑N/A c. 112x/month written followup d. ❑Monthly c. ❑Letter or computer report e. ❑ > Monthly d. ❑Magnetic tape e. ❑Combination of a+c, d or e b. Certified Length of stay a. x❑Yes a. ODaily a. []Phone call b. ❑No b. ❑Weekly b. ❑Phone call plus c. ❑N/A c. 02x/month written followup d. ❑Monthly c. ❑Letter or computer report e. ❑ > Monthly d. ❑Magnetic tape e. ❑Combination of a+c, d or e Procedure/service a. DYes a. ❑x Daily a. ❑Phone call determined NOT to be medically b. ❑No b. ❑Weekly b. ❑Phone call plus necessary c. ❑N/A c. 02x/month written followup d. ❑Monthly c. ❑Letter or computer report e. ❑ > Monthly d. ❑Magnetic tape e. ❑Combination of a+c, d or e d. Procedures where assistant a. ❑x Yes a. x❑Daily a. ❑Phone call surgeon determined not to be b. ❑No b. ❑Weekly b. ❑Phone call plus medically necessary c. ❑N/A c. 02x/month written followup d. ❑Monthly C. ❑Letter or computer report e. ❑ > Monthly d. []Magnetic tape e. [Combination of a+c, d ore e. Pre -op day(s) a. ❑x Yes a. ❑x Daily a. ❑Phone call determined not to be b. ❑No b. ❑Weekly b. ❑Phone call plus medically necessary c. ❑N/A c. 02x/month written followup d. ❑Monthly C. ❑Letter or computer report e. ❑ > Monthly d. ❑Magnetic tape e. ❑Combination of a+c, d or e -D * PacitiCare uses an integrated iJM/ claims payment system. 30 5. Indicate the primary method for determining the appropriate length of stay for a hospital admission. (CHECK ONE ONLY)(0) ❑ a. HCIA/PAS book for Region ❑ b. Internally developed written LOS table 0 c. Length of stay not preassigned ❑ d. Other purchased written LOS table (specify) ❑ e. Other: Percentile Year 6. Within the past twelve months, in what percent of all precertification cases was a letter of noncertification (denial) for MEDICAL NECESSITY/APPROPRIATENESS for the procedure/service issued? (Answer may require specific justification at a future date.) (CHECK ONE ONLY) (a6) VA 1.1 ❑ a. less than 1 % ❑ b. 1-2% 0 c. 3-4% ❑ d. 5-6 % ❑ e. 7-8 % ❑ f. more than 8 % ❑ g. not applicable What key written clinical criteria are utilized to determine the MEDICAL NECESSITY for a SURGICAL procedure. (CHECK ONE ONLY) (a8) e. f. 9. We do not review medical necessity during presurgical review. Milliman & Robertson. Sims (Interqual). No written criteria utilized. Case information individually Utilization Management staff nurse or physician reviewer. Internally developed written criteria set. Other purchased criteria: (Specify) Other: reviewed by For your non -worker's compensation clients, in the past 12 months, what percent of your preservice calls were classified as EMERGENT? (a13) ❑ a. Info not Available ❑ g.51-60% ❑ b. 0-10% ❑ h.61-70% ❑ c. 11-20% ❑ i.71-80% ❑ d. 21-30% ❑ j.81-90% ❑ e. 31-40% ❑ k.91-100% ❑ f. 41-50% -tl Emergent care does not require prior authorization. 31 9. Indicate the category of staff who can make final DISAPPROVAL for a preservice request (may check more than one). ❑ a. Clerical ❑ b. LPN/LVN ❑ c. RN 0 d. Physician 10. Are there precertification cases which could be approved by your non -RN personnel? © a. Yes, describe: All precertification staff is non -RN personnel. Dependent on the type of procedure, the request may be forwarded to a RN case manager. ❑ b. No 11. What percentage of ALL preservice reviews require your physician advisor review for decision making? (Check one) (a17) ❑ a. Less than 1 % ❑ b. 1 - 10% ❑ c. 11 - 19% 17 d. 20 - 30% ❑ e. 31 - 40% ❑ f. 41 - 50 % ❑ g. Greater than 50% 12. Indicate the MINIMUM number of hours your normal "business day" switchboard operation would coincide with an 8:00 a.m to 5:00 p.m. "business day" in ALL FOUR of the continental U.S. time zones (e.g., switchboard hours 8:00 a.m. to 5:00 p.m. Eastern time would coincide with a call availability of 6 hours Pacific time). (a26) 9 hours 13. Do you have a toll -free (1-800) telephone number for receipt of patient/provider calls? (CHECK ONE ONLY) (a27) ❑ a. No ❑ b. Will add prior to this client's implementation date. O C. Yes (Indicate): 1-800-877-9777 - EPO/POS members 1-800-255-1180 - PPO members 1-800-255-1189 - providers 32 14. Considering the size of the proposed client and possible volume of incoming phone calls, indicate your telephone system capabilities. (Check one.) (a31) 0 a. Present system clearly adequate to manage the anticipated volume of calls. ❑ b. Present system will need to be expanded, which will occur PRIOR TO the implementation date for Utilization Management services. ❑ c. Present system will need to be expanded, which will occur SHORTLY AFTER the implementation date for Utilization Management services. 15. What type of system is available for receipt of preservice calls BEFORE/AFTER your normal working hours? (Check one.) (a32) ❑ a. Answering machine with recorded message given. ❑ b. Answering machine will accept receipt of messages. 0 c. Answering service to receive messages. ❑ d. Open 24 hours a day. ❑ e. No provisions, except during normal business hours. 16. If a client wanted OUTPATIENT SURGERIES precertified, what specific services would you include in the presurgical review? (May check more than one.) (a33) ❑ a. We do not offer outpatient surgery precertification. 0 b. Medical necessity for the surgery. 0 c. Necessity for an assistant surgeon. 0 d. Necessity for a 23 hour/observation overnight stay. 0 e. Necessity for a post -op recovery center. ❑ f. Other: APPEAL/GRIEVANCE/RECONSIDERATION PROCESS 1. Do you have a formal written appeal/grievance/reconsideration process? (bl) 0 a. Yes ❑ b. No FA 3 Is there information regarding the option for an appeal, the timeframe and the mailing address in the body of any denial notification letter? (W) 0 a. Yes ❑ b. No In the last 12 months, considering 100% of your firm's appealed PRESERVICE review denials, what % of these UPHELD upon completion of the appeal? (b7) % Information not tracked in this manner 33 4. In the last 12 months, considering 100% of your firm's appealed CONCURRENT review denials, what % of these were UPHELD upon completion of the appeal? (b8) % Information not tracked in this manner CONCURRENT/CONTINUED STAY REVIEW Does your firm perform concurrent review services? ❑x a. Yes ❑ b. No (Proceed to next Section) 2. Indicate the locations which are reviewed under your concurrent review program. (d2) ❑x a.Review of cases in acute medical/surgical facilities 0 b.Review of cases in long term rehabilitation facilities 19 c.Review of cases in skilled nursing facilities 17 d.Review of cases in acute psychiatric facilities (Contracted to PBH) x❑ e.Review of cases in substance abuse rehabilitation facilities(Contracted to PBH) 3. Concurrent Review is performed: (CHECK ONE ONLY) (0) ❑ a. Telephonically for all cases. ❑ b. Telephonically in MOST cases with occasional onsite review needed. 17 C. Onsite in all cases. ❑ d. Onsite in MOST cases and telephonically where staff not available for onsite record review. ❑ e. Other: 4. Concurrent review staff are: (d4) a. 100% Full-time employees of the Utilization Management firm. b. _%Part-time employees of the Utilization Management firm. C. _%Subcontracted/consulting reviewers (e.g., on -call only, registry, home health agency personnel). 100% TOTAL 34 5. Check the category of staff who MOST FREQUENTLY perform telephonic concurrent review. (CHECK ONE ONLY) (0) ❑ a. Not applicable (Concurrent review performed only onsite.) ❑ b. LPN/LVN ❑ c. Trained clerical ❑x d. RN ❑ e. Physician ❑ f. Other: 6. Average number of concurrent reviews performed PER STAFF PER DAY: (CHECK ONE ONLY) (d8) ❑ a. 1 - 10 ❑ b. 11 - 20 ❑ c. 21 - 30 ❑x d. 31 - 40 ❑ e. 41 - 50 ❑ f. 51 - 60 ❑ g. More than 60 7. What percent of concurrent case reviews require your physician advisor intervention/review decision? (CHECK ONE ONLY) (0) ❑ a. 0% ❑x b. 1 - 10% ❑ c. 11 - 20% ❑ d. 21 - 30% ❑ e. 31 - 40% ❑ f. 41 - 50% ❑ g. 51 - 60% ❑ g. More than 60% 8. Is discharge planning an integral part of your concurrent review process and included in the fee for this program? (CHECK ONE ONLY) (d15) 0 a. Yes ❑ b. Yes, but separate fee for discharge planning services. ❑ C. No, discharge planning not part of concurrent review process or the fee. ❑ d. Other: 35 CASE MANAGEMENT 1 c 0 Does your firm have an ACTIVE case management program? (fl) ❑x a. Yes ❑ b. No (Proceed to Next Section) For the most current one year period, indicate the number of COMPLETED AND BILLED case management cases. (CHECK ONE ONLY) (2) ❑ a. 0 ❑ b. 1 - 40 ❑ c. 41 - 80 ❑ d. 81 - 120 ❑x e. If greater than 120 cases, indicate: 1000/year. During case management, does your staff NEGOTIATE FEE REDUCTIONS with providers and vendors? (CHECK ONE ONLY) (f3) © a. Yes ❑ b. No ❑ c. No, but willing to develop for this client. What is the AVERAGE percent fee discount this client could expect your firm to negotiate for service/equipment, etc.? (CHECK ONE ONLY) (f4) 19 a. Fees not typically negotiated. b. 1 - 5% C. 6 - 10% d. 11 - 14% e. 15 - 20% f. 21 - 25 % g. 26 - 30 % h. More than 30% Varies on a case -by -case basis. 36 5. Given your firm's average case management scenario, indicate the percent of total savings attributed to the following three categories: (fg) -0 Not available 6. What is the AVERAGE amount of time (billable hours) this client should expect that your Utilization Management firm spends on a TYPICAL case management case from initiation to closure? (CHECK ONE ONLY) (f11) ❑ a. 0 - 1.5 hours ❑ b. greater than 1.5 - 4 hours x❑ c. greater than 4 - 7 hours ❑ d. greater than 7 - 10 hours ❑ e. greater than 10 - 15 hours ❑ f. greater than 15 hours (specify) hrs. 37 STATISTICAL REPORTING Indicate your firm's ability to provide the following data for this client: (gl) 4 � a OVI ti� v �t _ a r a p tnitznly '%trtnl Regaes> � s bataiEIement& Additional' !cVJt' A a. Total number admissions or a. b. ✓ C. d. discharges b. Total number of bed days a. b. ✓ C. d. c. Total length of stay a. b. ✓ C. d. d. Admissions per thousand a. b. ✓ C. d. e. Bed days per thousand a. b. ✓ C. d. f. Average length of stay a. b. ✓ c. d. g. Admissions by service type a. b. ✓ C. d. or major diagnostic category or DRG h. Bed days by service type or a. b. ✓ C. d. major diagnostic category or DRG i. Length of stay by service a. b. ✓ C. d. type or major diagnostic category or DRG j. Admits by facility name a. b. c. ✓ d. k. Bed days by facility name a. b. c. ✓ d. I. Length of stay by facility a. b. c. ✓ d. name M. Admits by employee vs a. b. c. ✓ d. dependent n. Bed days by employee vs a. b. c. ✓ d. dependent 38 }6� w, y .Y NYC *, �ontmuec� [� x ¢6 L .Pa M•�•M d A a Can ^ 6Hf �� Y✓9�� N 3 �49hF-.d a �' �� : ,1Toi �:�es, xs „� ProAde a. Special ®_r E a� s olttinel I�outmeCy . ?u Request 1rovided Pdvidedi iti WITH �. <, r Additional ter'. Costi a o. Length of stay by employee a. b. C. ✓ d. vs. dependent p. Number of pre -certified a. b. C. ✓ d. cases by procedure name or ICD-9 q. Admit and discharge date by a. ✓ b. C. d. patient name or ID/SS# r. Length of stay by a. ✓ b. patient C. d. name or ID/SS# s. Number and name of cases a. ✓ b. C. d. receiving a second surgical opinion t. Admits by physician name a. ✓ b. C. d. u. Bed days by physician name a. ✓ b. C. d. v. Average length of stay by a. ✓ b. C. d. physician name 39 July 29, 1998 O'Neill, James RE: Proposal P-682 Page 2 For your use, I have attached the illustrations PacifiCare of Colorado used to compile the composite administration fees as well as the expected claims projections for the existing EPO and Point of Service plans. Mr. O'Neill, please note that the two PPO plan designs we have provided differ substantially from the current plan. I selected plans that most closely matched, but I encourage you to note the differences when evaluating our offering. The proposed rates are for the time period January 1, 1999 through December 31, 1999. The following are the 1999 benefit level and contract changes for the existing EPO and Point of Service contract with PacifiCare of Colorado: • Eye examinations will now be covered once every 12 months rather than every 24 months. • A member's out-of-pocket maximum will now be $2,500 single / $7,500 family (in the past this amount was $3,600 single / $10,000 family). • Insulin pump supplies will now be covered. • Podiatric shoe inserts and braces for members who meet criteria will now be covered to $500 per member, per contract year (in the past, they were covered only to $250). All other durable medical equipment, including oxygen, will now be covered to $1,500 per member per contract year (this was $1,000 previously). • An inpatient hospital copayment will now be required for each admission. Previously, a copayment was required only for the first two admissions in any contract year. • Copayments applicable to the infertility benefit will no longer cease at $2,500 out-of- pocket maximum. Infertility copayments will now apply to the overall plan out-of- pocket maximum of $2,500. Additional Products that PacifiCare Offers Lastly, while I realize you are not currently entertaining quotes for dental or life insurance, the following is information on both of these products and our retiree plan which PacifiCare offers in addition to our commercial plans. If you have an interest in any of these products, please let me know. 2. If the following information (3 grids) was needed from your Utilization Management firm at least quarterly, indicate your firm's ability to provide this required information. (CHECK ONE ONLY) (g3) ❑x a. Yes, capable of providing the information contained in the three grids on a quarterly basis at NO additional cost. ❑ b. Yes, capable of providing the information contained in the three grids on a quarterly basis WITH additional cost. ❑ c. No, unable. GRID 1 Original Precertification Cases Number Approved Number Avoided* Number Denied* Number Waived* Inpatient medical/surgical Outpatient surgery Inpatient psychiatric/ substance abuse Outpatient psychiatric/ substance abuse Outpatient services (e.g. doctor office, PT, OT, chiropractic, etc.) Equipment/appliances Diagnostic tests TOTAL * Definitions of terms in preceding grid: AVOIDED = cases where your firm's staff persuaded physician to seek an alternate more cost effective route/service than had been called into certify without having to issue a denial (e.g., physician concurred with your Utilization Management firm's recommendation). WAIVED = cases where client overturned Utilization Management firm's recommendation for denial/noncertification. DENIED = cases where your firm issued a letter of noncertification (e.g., denied necessity for service). 40 GRID 2 * The cases which were (a) avoided, (d) denied and (w) waived are to be specifically recorded and provided as an attachment to the Utilization Management Grid #1 to include: Enrollee Sex Original Requesting Date Review Rationale Age Request Dr of Status: for: Service (a) (a) (d) (d) (w) (w) GRID 3 Concurrent/Continued Stay Number of Cases Total Length of Stay Average Length of Stay Inpatient medical Inpatient surgical Maternity/obstetrics Psychiatric Substance abuse TOTAL 3. How often should the client expect to receive a ROUTINE report from your firm indicating overall utilization and savings? (CHECK ONE ONLY) (g4) ❑ a. Weekly ❑ b. Monthly ❑ c. Quarterly ❑ d. Semi-annually (every 6 months) ❑ e. Annually 17 Overall Utilization is reported monthly, while savings is reported quarterly 4. Are you able to provide an annual summary of the client's utilization statistics and your firm's overall savings? (95) © a. Yes ❑ b. No 41 5 VA Indicate your STANDARD METHOD OF REPORTING SAVINGS from review of INPATIENT hospitalization. (CHECK ONE ONLY) (g6) ❑ a. Inpatient hospital savings reports not available. ❑ b. Basically as the difference between days requested and days approved/certified. 19 c. Basically as a comparison of days or length of stay utilized versus normative or case mix adjusted days or length of stay. ❑ d. Other: Describe: Indicate the STANDARD METHOD OF REPORTING SAVINGS from review of OUTPATIENT surgery. (CHECK ONE ONLY) (g7) ❑x a. Outpatient surgical review not available. ❑ b. Outpatient surgical review available but specific reporting not delineated. ❑ c. Dollar value times the number of cases determined not to be medically necessary. ❑ d. Other: Describe: Indicate if the outcome of your review activities in the following categories is able to be provided on client reports. (CHECK ONLY THOSE WHICH CAN BE PROVIDED.)(g8) 1 a. Number of cases determined to be medically necessary. b. Number of cases determined to be NOT medically necessary. C. Number of cases diverted from inpatient to outpatient. d. Number of cases where requested assistant surgeon was approved. e. Number of cases where requested assistant surgeon was NOT approved. f. Number of cases where a proposed preop day was approved. g. Number of cases where a proposed preop day was NOT approved. h. Number of cases where a proposed 23 hour observation stay following outpatient surgery was approved. i. Number of cases where a proposed 23 hour observation stay following outpatient surgery was NOT approved. j. Number of cases where outpatient surgery was approved. k. Number of cases where outpatient surgery was NOT approved. 42 QUALITY CONTROL 1. Do you have a mechanism to ensure that data entry is ACCURATE and COMPLETE?01) ❑ a. No 17 b. Yes, explain: Reconciliation at the end of the month. 2. 3 n 5 181 Do you have a mechanism to ensure the consistent application of written screening criteria by your nurse reviewers? 02) ❑ a. No ❑x b. Yes, explain: Inter -rater Reliability tests When reviewing a case for which no specific written criteria exists, is the case AUTOMATICALLY referred to a physician advisor? 0 7) ❑ a. No (Describe your protocol) © b. Yes Do you have a mechanism to monitor whether your PHYSICIAN ADVISOR REVIEW DECISIONS are reasonable and cost effective? 03) ❑ a. No 0 b. Yes, explain: Inter -Rater Reliabilit tests Does your Utilization Management firm maintain PRODUCTIVITY STANDARDS for nurse reviewers (e.g., "X number of reviews must be completed each day", etc.)? 04) 19 a. No ❑ b. Yes, describe: Do you monitor to assure that reviews are completed in a TIMELY manner? 05) ❑ a. No 17 b. Yes, explain how: Audit every case 43 GENERAL QUESTIONS 1. How long has your organization been performing Utilization Management services? (CHECK ONE ONLY) (nl) ❑ a. Less than 1 year ❑ b. 1 - 3 years ❑ C. 4 - 6 years ❑ d. 7 - 9 years 0 e. 10 or more years 2. Are your services local, national, or international? (CHECK ONE ONLY) (n2) ❑x a. Local only ❑ b. National, some states* ❑ c. National, all states ❑ d. National, all states plus international * Indicate the states you SERVE or DO NOT SERVE (whichever is shorter). Currently serving the Colorado region as reflected in Network Service Area attachment. 3. What percent of your primary operational staff involved in preservice, concurrent and case management review have been with your firm for ONE YEAR OR LONGER? 95 (0) 4. Are there any specific reporting or administrative procedures you would require of this client prior to implementation of your program? (n4) ❑ a. Yes, explain: ❑x b. No 5. Considering this client's START DATE for U.R. SERVICES, do you foresee any difficulty in the installation of your program? Give timeline proposed. (n5) © a. No ❑ b. Yes, explain: 6. Would you be agreeable to a periodic (e.g., quarterly) "round table" meeting with the client, Utilization Management firm, claims payor and consulting organization to discuss both positive and negative areas of the working relationship? If yes, consider this cost in your proposed fees. (0) ❑x a. Yes ❑ b. No 44 7. Indicate your fi m's per occurrence liability INSURANCE LIMIT with regard to errors, omission, negligence, malpractice. (CHECK ONE ONLY) (n10) ❑ a. < $1,000,000 ❑ d. $5,000,000 ❑ b. $1,000,000 ❑ e. > $5,000,000 but < $10,000,000 x❑ c. > $lM but < $5M ❑ f. >=$10,000,000 -0 Excess capacity to $50 million is retained through self-insurance. 8. On cases where any adverse decision has been rendered, are you willing to retain hard copy U.R. and medical information files for a period of one year POST contract termination? (CHECK ONE ONLY) (n15) x❑ a. Yes, at no added cost ❑ b. Yes, with an added cost $ ❑ c. No, explain: 9. Do you have educational material which informs enrollees regarding your U.R. services and Procedures? (CHECK ONE ONLY) (nl8) [7 a. Yes, available for this client at no added cost ❑ b. Yes, available for this client with an added cost of $ ❑ c. No, but can develop at no added cost ❑ d. No, but can develop with an added cost of $ ❑ e. No, not available 10. Is your firm willing to assist this client if a dispute arises over payment/nonpayment for health care services which your firm recommended were not medically necessary, appropriate and/or reasonable? (CHECK ONE ONLY) (n20) 19 a. Yes, within our proposed fees ❑ b. Yes, for an added cost $ ❑ c. No, explain: 11. Is your firm willing to assist the City with medical appeals when special questions or situation arise? Yes, PacifiCare is available for answers and also assistance with medical appeals. 45 12. What is your response time for returning phone calls/messages? PacifiCare standard response times are as follows: 13. When approval or denial is granted for a procedure, what is the procedure for notification, who is contacted and what is the timeline? When PacifiCare is contacted by a physician/member for a requested procedure/service and PacifiCare denies the authorization, the following occurs: If the denial is based on lack of medical necessity, the case is reviewed and signed by the Medical Director prior to written communication by Medical Management staff. The Medical Necessity Review form will be forwarded to the appropriate Medical Management staff and attached to the denial letter copy for filing and imaging. The denial or authorization will be communicated in writing to the member and physician within One (1) working day after PacifiCare makes the decision. Every written response informs the member of the reason for the denial and the right to appeal the decision specific to the member's Evidence of Coverage which addresses the appeals process. In addition, on a quarterly basis, a report outlining initial denials will be presented to the Plan's Medical Management/Provider Services Director's meeting. Analysis of this data will be reported to the Evidence of Coverage Committee and Criteria Committee when appropriate. 14. Will a U.M. representative be assigned solely to the City? If not, what will the arrangement be? Utilization Management staff are trained to handle utilization issues for all clients. 15. What organization would provide the utilization review services, where is its headquarters and where will the utilization review services be provided? PacifiCare of Colorado performs all utilization review services in house, and is headquartered in Englewood, Colorado. 46 16. Will your firm agree to modify procedures to meet the needs of the City? No, PacifiCare does not modify utilization programs that are in place for client specific purposes. 17. The City is considering the addition of an Employee Advocacy Program which would provide assistance to employees regarding self care, general medical care, second opinions, selection of providers, etc. This program would be accessible to employees through a WATS telephone service during normal business hours. This service would be provided by personnel with the appropriate medical background to accurately answer questions. If the City were to add an Employee Advocacy Program: a) What type of personnel would provide these services? What type of credentials would these individuals possess? b) How would quality be assured and measured through this program? c) How many hours per day would this service be accessible through a live attendant? Days per week? d) Have you implemented a similar program for any other clients? If so, what were the financial impacts on the Plan compared to the investment? Customer Services hours of operation are 7 AM to 6 PM Monday through Friday. Although PacifiCare does not provide a 24 hour call in line, we do have an answering service for those hours customer service representatives are not available. PacifiCare also requires all contracted primary care physicians to have 24 hour on -call availability. 18. Describe how psychiatric/substance abuse reviews will differ from other utilization services. Are these services subcontracted or provided within your organization? If done within, what are the credentials of the individuals performing this service? Mental Health and Substance Abuse services are provided through PacifiCare Behavioral Health, Inc. (PBH). PBH is one of the nation's leading behavioral health care companies. A wholly owned PacifiCare subsidiary and affiliate to PacifiCare Life & Health Insurance, PBH offers a capitated behavioral health plan, providing both inpatient and outpatient treatment, precertification and concurrent review and employee assistance services. They also have EAP services available as an option. 47 19. Are there any other services that are subcontracted? PacifiCare Life & Health PacifiCare Life & Health, formed in 1986 and licensed in 33 states, provides competitive life insurance options and serves as the underwriter for PPO/indemnity Medicare plans. Prescription Solutions PacifiCare's managed pharmacy program, Prescription Solutions, offers both mail- order prescription services and a network encompassing most major drug and grocery store chains as well as independent pharmacies. PaciiiCare Dental & Vision PacifiCare Dental, founded in 1972, is licensed under the Knox -Keene Health Care Plan Act as a provider of prepaid dental plans for individuals and groups. Putting an emphasis on service has placed PacifiCare Dental among the largest providers of prepaid dental health plans in the west. 20. Are there or have there been any lawsuits brought against your company? Please describe in detail. No, PacifiCare has not had a lawsuit brought against the company in the past year. 48 REQUESTED ATTACHMENTS Please provide the following: 1. PRESERVICE REVIEW a. Include a sample preservice confirmation/approval notice/letter. b. Include a preservice denial/nonconfirmation notice/letter. Preservice Review attachment 2. CONCURRENT REVIEW a. Provide a sample letter indicating that continued stay is longer able to be certified/approved. PacifiCare approves concurrent stay via telephone. 3. CASE MANAGEMENT a. Include a sample case management summary report with savings analysis. (Do not identify the patient or providers of service.) b. Include a sample bill which this client could expect to receive for a case management patient. PacifiCare does not provide reports with savings analysis, or bill clients for case management. 4. REPORTS a. Include a sample standard report package with an explanation of abbreviations and categories of data. b. Include samples of customized report capabilities. previous Sample Utilization Reports attachment 5. APPEAL PROCESS a. Attach a copy of the detailed appeal process a patient, physician or provider would need to follow in the resolution of a complaint/disagreement including key timeframes. b. Attach a sample appeal closure letter which would be forwarded to a physician. 49 July 29, 1998 O'Neill, James RE: Proposal P-682 Page 3 • PaciriCare Dental PacifiCare offers both HMO and PPO dental plans and they are now available on a stand alone basis. The HMO plans are designed to offer cost effective benefits with easy access to quality care. PacifiCare dental members receive comprehensive care through our network of private practice dental offices. All dental care is coordinated through a primary care general dentist who is selected by the member at the time of enrollment. The PacifiCare Dental Century Plans (HMO Dental) are "scheduled" plans. This means that charges for procedures cannot change for the life of the plan. Therefore, a member is guaranteed that copayments will not increase. Additionally, to encourage better dental health and long-term cost management, all PacifiCare Dental Century Plans provide coverage for diagnostic and preventive care at no cost to the member. Eight plan designs, with both voluntary and employer contribution offerings, are available. There are five PPO plan designs available with an extensive PPO network panel. Out -of -network benefits are comparable to a traditional Indemnity dental plan. • Retiree Plan PacifiCare's Secure Horizons program is available to employers who wish to offer quality benefits to their retirees and minimize the impact on their health care costs. Secure Horizons Medicare risk programs have been developed to offer a comprehensive solution to the challenges associated with funding retirement health care benefit programs. Advantages to the employer include: low premium rates, selections available on several different plans, potential reduction in operating liability, and implementation at little or no cost to you. Advantages to the retirees include low office and hospital copayments, no deductibles, no paperwork, preventive care, a senior plan customer service department, optional prescription benefits, orientations on health and lifestyle issues, and worldwide coverage for emergencies. Secure Horizons expertise in Medicare risk plans has earned the position as the largest Medicare risk contractor in Colorado. We are proud to now serve more than 30,000 Senior Members. Appeal Process attachment 6. ADMINISTRATIVE a. Include sample education material which informs enrollees regarding your Utilization Review firm's overall services. PacifiCare does not provide utilization review educational materials to members. b. Include a sample Utilization Review contract. Proprietary information c. Briefly describe a Utilization Management program/process/tool developed by your firm which you believe is innovative in controlling or measuring health care costs. Utilization Management has two excellent case management programs: Diabetes: There are several facets to the diabetes health management program offered by the health plan. • New members joining the plan are contacted telephonically by one of the health management/case management nurses. These members are assessed as to any specific diabetes management needs they might have as they join the plan and the nurse works with them and their primary care physician to assure these needs are met as they join the plan. • A targeted patient counseling program that includes both telephonic and written self -directed materials is provided to members. This intervention is in collaboration with part of a larger corporate wide intervention for diabetes called "Taking Charge of your Diabetes". Both nurses from the health management area and health educators from the Health Improvement department are involved in this intervention. • Members identified with specific diabetes management problems either by their primary care physician or self report can also be followed individually by one of the health management/case management nurses until their specific problem is solved. Two staff in the health management/case management area are Certified Diabetes Educators. They are available to either manage difficult problems or as a resource to other staff managing these members. Congestive Heart Failure: There are two primary components to the Congestive Heart Failure Program 50 1. Members hospitalized with congestive heart failure are entered into a post hospital telephone follow-up program at the time of their discharge from the hospital. Nurses follow a protocol based program with these members aimed at improving their recognition of symptoms, compliance with medical regimen for managing congestive heart failure and lifestyle modification to improve their condition. Nurses work closely with the member's primary care physician and other community resources in this program. 2. The second component of the Congestive Heart Failure Program is also part of a larger corporate wide intervention called "Taking Charge of your Heart Health". Members are identified for this program either through self report or claims and encounter information. They are called on the telephone by one of the health management nurses. Their needs are assessed and they are steered towards appropriate resources. Educational material mailed to the member is part of this intervention. d. Does your organization offer disease management programs? If so, describe including chronic conditions evaluated, length of program, savings and associated costs. Are the costs included in your quotation or are they additional? Yes, PacifiCare recognizes the importance of identifying and providing support services to members in the health plan who have specific health problems. At this time there are six major methods we use to identify members identified as at high risk. During 1996, specific attention was paid to developing a population management registry system. PacifiCare identified specific health conditions that were determined to be high risk conditions. 30% of the PacifiCare population under age 65 has one of these identified conditions and 50% of the population above age 65 has one of the conditions. As a result of the development of this system, several strategies are in use to improve our service level to these members. In the PacifiCare system, the primary care physician is the cornerstone of patient care. Through our registry process, we offer to individual physician profiles of their members who have high risk medical conditions. As these profiles are provided we are able to discuss with the physician support services he or she needs to more effectively manage this group of members and offer assistance from PacifiCare case managers to assist with specific individuals. A second method of identifying members at increased risk is through health risk appraisals at employer -based screenings. As members are identified with specific health risks by PacifiCare staff, the information is shared with the member and with the PCP. Individual follow-up plans are determined based on the nature of the member's situation. 51 A third method of identifying members at increased risk is through the PacifiCare Senior Entry Survey that is offered to all new members enrolling with the Senior Medicare Product. This entry survey is based on several nationally validated tools utilized to identify those members who may have specific conditions which can benefit from special intervention. A comprehensive intervention approach is implemented as specific categories of members at risk are identified. The approach varies including individual case management, notification and planning with individual primary care physicians, and encounter monitoring to assure that services are being offered. A fourth method of identifying members at increased risk is through monitoring of specific diagnoses of hospitalized members to identify populations at risk. As a result of this type of casefinding, on ongoing outreach program for those members who have been hospitalized with congestive heart failure (CHF) has been implemented. Through the CHF program, PacifiCare staff work with both the member and the primary care physician to assist the member to successfully cope with their illness and reduce the probability of their being re -admitted to the hospital. A fifth method of identifying members at high risk is through review of specific claims information to find those members who appear to be outliers and need special intervention based on certain indicators such as accumulating more than a specified dollar amount of claims. A sixth method of identifying members at high risk is through self referral by the member or referral by the primary care physician. An example of self referral is the Small Wonders High Risk OB program offered to all PacifiCare members. Pregnant members are contacted and encouraged to participate in this medical management program. During the pregnancy, periodic contact is maintained with the member to facilitate any special care needed. Case management nurses evaluate Approx. 10,000 the member's need for education. Has been in place statewide members Diabetics referred Diabetic Increase awareness of how it for several years have diabetes for special Program affects life & precautions services AIDS A nurse coordinates with member's Members with PCP and oversees case for quality Still in AIDS identified & appropriateness of care. development through case Heart Failure A "Heart Failure" workgroup, which Physician concerns management deal with homecare agencies, 1995 and the addition of Members with skilled nursing facilities and Senior Plan added to heart failure hospitals. the frequency of the identified through condition case management Asthma Improve maintenance of the High ER or hospital Members with Management disease at a non -acute level and Approximately utilization asthma identified help decrease admissions and ER 1994 through case services for this diagnosis. management 52 Complete the grid regarding your firm's Utilization Management services. Check (X) the Type of Service Number of Firms Number of Type of Client Participants General Worker's Medical Compensation Taft -Hartle Trusts N/A Single employer X All contracted All members corporate groups Government (State/Fed) X All contracted All members groups Municipalities X All contracted All members (city/county) groups Schools X All contracted All members groups Associations X All contracted All members groups Other TOTAL 53 STOP -LOSS INSURANCE QUOTATION FORM Please provide an individual stop -loss quotation for the following deductibles. The following must be a schedule of stop -loss premium rates before any dividends or experience refunds. PPO Plans Only Paid Rate Per Eligible Per Month Expected Incurred Claims Per Month Individual Stop -Loss coverage based on all claims incurred after October 1 1998 and paid after January 1. 1999 with the following deductibles: $120,000 Employee $ 5.74 $ 203.58 Employee + Spouse $ 12.63 $ 441.77 Employee + Child(ren) $14.06 $ 490.64 Employee + Family $ 19.51 $ 682.09 $135,000 Employee $ 4.31 $ 203.58 Employee + Spouse $ 9.50 $ 441.77 Employee + Child(ren) $ 10.57 $ 490.64 Employee + Family $ 14.67 $ 682.00 $150,000 Employee Employee + Spouse $ 3.75 $ 203.58 Employee + Child(ren) $ 8 26 $ 441.77 Employee + Family $ 9.19 $ 490.64 $ 12.76 $ 682.00 x includes claims above and below specific stop -loss. Note: Excludes Medicare Retirees. Coverage must include prescription drugs and exclude organ transplant coverage. for purposes of our quote, please assume the following for the PPO plans: Employee 190 Employee + Spouse 130 Employee + Child(ren) 60 Employee + Family 220 Total 600 54 STOP -LOSS INSURANCE QUOTATION FORM (continued) Rate Per Eligible Per Expected Incurred Claims POS/EPO PLANS ONLY PAID Month Per Month Individual Stop -Loss coverage POS EPO POS * EPO based on all claims incurred after October 1, 1998 and paid after January 1, 1999 with the following deductibles: $120,000 Employee $ 4.78 $ 4.55 $ 151.19 $ 122.47 Employee + Spouse $ 10.53 $ 10.03 $ 332.63 $ 269.44 Employee + Child(ren) $ 11.73 $ 11.17 $ 377.99 $ 306.19 Employee + Family $ 16.28 $ 15.50 $ 514.06 $ 416.41 $135,000 Employee $ 3.60 $ 3.43 $ 151.V $ 122.47 Employee + Spouse $ 7.92 $ 7.55 $ 332.63 $ 269.44 Employee + Child(ren) $ 8.82 $ 8.40 $ 377.99 $ 306.19 Employee + Family $ 12.24 $ 11.66 $ 514.06 $ 416.41 $150,000 Employee $ 3.13 $ 2.98 $ 151.19 $ 122.47 Employee + Spouse $ 6.88 $ 6.55 $ 332.63 $ 269.44 Employee + Child(ren) $ 7.65 $ 7.29 $ 377.99 $ 306.19 Employee + Family $ 10.63 $ 10.12 $ 514.06 $ 416.41 * Includes claims above and below specific stop -loss. Note: Excludes Medicare Retiress. Coverage must include prescription drugs and exclude organ transplant coverage. For purposes of your quote, please assume the following eligibility for the POS plan and EPO plan: POS EPO Employee 30 185 Employee + Spouse 10 100 Employee + Child(ren) 15 95 Employee + Family 25 205 Total 80 585 How do the above charges differ assuming you are selected to provide stop -loss coverage for all plans? 55 STOP -LOSS INSURANCE QUESTIONS TO BE ANSWERED 1. Please explain your company's renewal action procedures with respect to the stop -loss contract. Can individuals be excluded or given higher deductibles due to adverse claim experience? jf so, describe under what circumstances. No, individuals cannot be excluded or given higher deductibles due to adverse claim experience. 2. How often would your company audit claims payments and procedures? For HMO business, all bills over $20,000 are audited internally to confirm fees and charges. If questions concerning a bill arise, personnel from the Medical Management department are consulted. The savings may vary significantly depending on the charges involved. For PPO business, any claim over $10,000 is referred to the Manager of PPO Claims. It is reviewed for percentage of ancillary services and the three highest ancillary categories are reviewed further. If the Manager determines it appropriate, the bill goes to audit. PacifiCare contracts with an outside vendor for auditing. 3. Is a claim audit necessary before stop -loss claims can be paid? If so, please describe the nature and length of the process. No, a claim audit is not necessary before stop -loss claims can be paid. 4. How soon after a claim is submitted to your company can reimbursement be expected by the City? Standard turnaround time is 85% processed within 30 days. 5. How are discrepancies between your company's definition of a usual, customary and reasonable charge and that of the claim administrator handled? Discrepancies would exist between PacifiCare and the person/provider awaiting reimbursement. These matters are resolved using Lincoln Reinsurances' definitions of usual, customary and reasonable. 56 6. Will your company underwrite stop -loss coverage without also acting as the claim administrator? If yes, describe your TPA approval process and length of time to complete. Yes, Lincoln Reinsurance will provide stop -loss without PacifiCare being the administrator. 7. Your company must assume responsibility under stop -loss for existing COBRA continuees at the time coverage is effective. Please confirm your acceptance of this requirement. PacifiCare needs clarification on this question. 8. Does your company allow for rating credits if certain claim administrators, claim audits or utilization review programs are utilized? If so, please list these administrators and/or .programs as well as the corresponding credit. No, we do not allow for rating credits if certain claim administrators, claim audits or utilization review programs are utilized. 9. Describe the precise term of coverage under your quoted individual stop -loss provisions (e.g., claims incurred on or after the plan effective date and paid within 120 days of the end of the contract year or termination, whichever is earlier). Term of coverage is considered paid within contract 1/1/99 - 12/31/99. 10. Please define a paid claim. A claim is considered paid when services have been rendered, the claim processed and payment issued. 11. What is the approximate size of your stop -loss portfolio in terms of annual premiums and lives covered? Is there any reinsurance of the pool? If so, please describe. Commercial HMO $300,000. Self -funded groups insure themselves at an average of $75,000 Yes, we sell aggregate coverage through Lincoln National Reinsurance. 12. Are premiums established solely on the basis of the experience of that pool, or are other factors such as plan's own experience and reinsurance rates considered as well? Premiums are established on the basis of the experience pool, adjusted for the own groups demographics. 57 13. Are there any events that can occur during the term of the stop -loss contract that permit you to adjust your rates (e.g., changes in enrollment or benefits of certain magnitude)? No, rates are not adjustable. 14. Are there any dollar limits under your stop -loss liability? HMO reinsurance (Stop -loss) limits: $2,000,000 per individual, per lifetime $300,000 deductible 15. Do you agree to cover all charges permitted under the terms of the plan? If not, what exclusions and/or limitations exist with respect to what your contract will cover? Yes, all charges permitted under the terms of the plan are covered except outpatient mental health charges in excess of 100 visits per year. 16. Does your stop -loss coverage contain any mental health or other restrictions? If so, please explain. Yes, charges in excess of 100 outpatient mental health visits per year. 17. On individual claims exceeding the individual stop -loss deductible, is the City responsible for payment or will your company provide a draft book or actually process and pay the claim? If the City is responsible, will you require the City to make an actual payment or will you reimburse the City on submitted expenses? The City of Fort Collins pays the claim, and Lincoln Reinsurance reimburses the City. 18. Will your company provide an annual experience accounting report for a stop -loss policy showing premium paid, benefits paid (if any) and retention charges? Yes, this information is provided on the Monthly Experience Summary. 19. Will you agree to conform with the provisions of the Plan in regard to pre-existing conditions? Yes, we agree to conform with the provisions of the Plan in regard to pre-existing conditions. 20. Will you consider alcoholic, chemical dependency or drug addiction treatment, as provided for in the plans of benefits, as eligible expenses under a stop -loss contract? This is subject to the provisions of the Plan. 58 21. These specifications have asked for your proposal to underwrite individual stop -loss coverage on a "15/12" basis. The attachment point would be based on those claims incurred October 1, 1998 through December 31, 1999 and paid within the contract year, January 1, 1999 through December 31, 1999. Is this your understanding of the individual stop -loss specifications? As Lincoln ,Reinsurance is the existing carrier, our quote is based on a paid contract 1/1/99 - 12/31/99. 22. Confirm that your proposal is net of organ transplant coverage. Yes, this proposal is net of organ transplant coverage. 59 July 29, 1998 O'Neill, James RE: Proposal P-682 Page 4 • PacifiCare Life Insurance PacifiCare Life Assurance Company offers group term life insurance, accidental death and dismemberment insurance, and supplemental life insurance at competitive rates. As an A.M. Best rated "A-" company, PacifiCare Life Assurance is your health care partner providing a wide variety of group life and health products to fulfill your employee's needs for a full service carrier. Thank you again for the opportunity to continue providing health care coverage to the City of Fort Collins. Please let me know if you have any questions or need anything further at (303) 714-3463. Sincerely, Christine Lawrence Account Manager /cl Enclosures: Four Bound Copies of Proposal Four Copies of EPO/POS and PPO Sample Communication Materials PRESCRIPTION DRUG PLAN PacifiCare is not quoting the Prescription Drug Plan. Administration of pharmacy services is not available on a carve out basis; therefore, this section is not completed. The costs associated with the administration of the drug plan, as part of a medical plan quoted, are included in the TPA Services fee. GENERAL QUESTIONS TO BE ANSWERED BY ALL PROPOSERS All proposals submitted must include answers to the following questions: Administrative Agreements and General Information 1. It is the intention of the City that the master contract reflect the elimination of the actively -at -wort restriction or deferred effective date for all initially enrolled active or inactive employees and dependents. This will include only initial eligibles (those eligible on the effective date of the contract) including COBRA continuees. Please indicate your acceptance to this requirement. Agreed, provided they are covered under the current policy. 2. It is required that proposals assume that all participants (including COBRA) presently covered will be covered under a successor plan regardless of medical condition, disabled status, or whether they are actively -at -work or on a no -loss no -gain basis for both the City and the participant. Is your proposal written in accordance with this requirement? Yes, this proposal is written in accordance with the stated requirement, provided these participants are covered under the current policy. 3. If your company is awarded this business, how soon after notification of the award would you be able to have a draft of the contract? Within 30 days for all plans offered. 4. If the services furnished by your company differ in any respect from those described, please indicate where such differences exist. If you do not indicate any differences, it will be assumed that the services included in your proposal do, in fact, exactly match those described. The PPO quoted is a standard PacifiCare plan and differs from the current plan offered. Please refer to PPO Benefit Summary attachment. 5. Provide a sample contract similar to the one that would be used for the City. City Standard Services Agreement is enclosed as Exhibit _, note specific exception or changes requested. A copy of the existing EPO/POS contract is available as an insurance contract. The Standard Services Agreement presented herein would not apply. 60 6. Commissions or fees of any type are not to be paid to any entity as part of the cost of the services requested in this specifications letter. Is your proposal written in accordance with this provision? Yes, this proposal is written in accordance with the stated provision. 7. Please provide,at least three Colorado (preferably municipality plans with at least 500 employees) references (not current Segal Company clients) for each service you are proposing. List the name of the organization, address, telephone number, and contact person's name and title. If your company is quoting all or a portion of the benefits included in this Request for Proposal, please provide references for each benefit you are proposing. Also, provide the name and telephone numbers of any clients you are not now serving that you were serving three years ago. Why are you not providing service to these clients? CLIENT REFERENCES Employer Federal Government Contact Name & Title Sharon Kni ht, Benefits Specialist Address 1900 E Street NW Room 3451 City, State Zip Washington, DC 20415 Telephone Number 202-606-0755 T Employer Colorado Educational Benefit Trust Contact Name & Title Frank Urman, President - The Urman Company Address 5660 Greenwood Plaza Blvd., Suite 330 City, State Zip Englewood, CO 80111 Telephone Number 303-773-1373 Employer Hewlett- Packard Contact Name & Title Marlene Disney, Benefits Administrator Address 3404 East Harmony Road City, State Zip Fort Collins, CO 80525 Tele hone Number 970-2293465 61 FORMER CLIENTS Employer Bolle America, Inc. Contact Name & Title Kim Krause Address 3890 Elm Street City, State Zip Denver, CO 80207 Telephone Number Term due to: 303-321-4300 Rate increases Employer Colorado State Employees Credit Union Contact Name & Title Leo Perino Address 1390 Loan Street City, State Zip Denver, CO 80203 Telephone Number 303-812-1882 Term due to: Rate increases Employer Citv of Pueblo Contact Name & Title Beth Vega, Personel Address 1 City Hall Place City, State Zip Pueblo, CO 81003 Telephone Number Term due to: 719-584-0815 Rate increases 8. Provide samples of any communication materials that would -,be provided by your company to the City at no additional cost. What customized materials are available? Please identify the retention costs associated with these communication materials. Please refer to Communication Materials attachment. Customized materials are reflected in the Sample Utilization Reports attachment 9. Would you agree to contractual performance guarantees regarding telephone calls, referrals, access standards, i.d. cards, NCQA accreditation? Please provide the specific standards and examples of similar arrangements with other clients. Yes, PacifiCare would agree to contractual performance guarantees regarding several issues. PacifiCare holds this type of agreement with several contracted groups. Please refer to Sample Performance Guarantees attachment. 10. The City will require that contracts include language that any data associated with the City's plan is the property of the City and, as such, must be available to the City (e.g., when changing vendors). Please indicate your acceptance of this requirement. Information only for the transfer of plan (i.e. lifetime benefit, deductible accumulation, etc) will be provided. 62 11. Record keeping: a. Discuss how participant/retiree and dependent records are maintained. Eligibility records are maintained on the RIMS system and are sorted by location per client request. We rely on the client for updated information and process 99% of enrollments, terms and changes within 3 days of receipt. b. Will your organization verify eligibility from an electronic format of the District's choice? PacifiCare does offer Electronic Data Interface (EDI) capabilities to employers utilizing ANSI X-12 national standards. Those employers unable to comply with ANSI X-12 standards may instead submit eligibility .according to PacifiCare's standard tape -to -tape reporting format. We would be happy to discuss implementation timetables in detail with the group- C . Eligibility reconciliation meetings with the District will be held quarterly at additional cost. Do you agree with this requirement? PacifiCare is willing to meet with the District on a quarterly basis in order to reconcile eligibility. We would be willing to discuss any costs associated with these meetings. 12. arm that you will be Year 2000 compliant, and describe your procedures to become compliant. Year 2000 Position Statement PacifiCare Health Systems (PHS) is well underway to becoming Year 2000 compliant. At PHS we are knowledgeable of solutions for the Year 2000 and have implemented a comprehensive Year 2000 project plan that encompasses all areas of the corporation. The plan was implemented in May 1996, and is scheduled to be completed by the end of 1998. The Year 2000 plan is being used by personnel throughout the organization. They are altering systems, reports, etc., to allow dates beyond December 31, 1999, to be properly represented and processed in all corporate systems and hardware. Additionally, comprehensive weekly reports are being generated that track the detailed progress of all system compliancy. 63 We are also contacting all software vendors to obtain a "statement of compliance" with Year 2000 issues. Furthermore, we are verifying vendor compliance in our own environment, including full Year 2000 simulation testing. Project Milestones as of March 1998: Coinpleted Milestolle Due Date Status 100% Planning: January 1997 Completed 27 core systems 1,300 components over 2 million lines of code 100% Analysis & Design November Completed 1997 95% Coding May 1998 In progress 90% Vendor Compliance September In progress 1998 30% Testing November In progress 1998 Pending Implementation (full December Pending completion of certification) 1998 testing The integration of former FHP markets into PHS' systems is on schedule for completion by the end of 1999. As all PHS systems will be Year 2000 compliant by the end of 1998, these former FHP markets will also be compliant at the final integration date. This will ensure that there will be no issues for our customers as we move into the Year 2000. In addition to all major computing systems, PacifiCare's Business Units are verifying that all date fields and calculations used in "home-grown" software and other departmental business solutions will be Year 2000 compliant by the end of 1998. PacifiCare is also planning to roll out an enterprise -wide initiative across all segments of the corporation in early 1999 to address possible non -Year 2000 compliant business partners and service providers, and to implement contingency plans. PacifiCare Health Systems recognizes how critical it is to our business and is committed to becoming Year 2000 compliant. 64 13. How does your organization handle the surcharge requirements of New York and Massachusetts? What impact do these surcharges have on your clients (e.g., describe charges, if applicable)? PacifiCare recommends the City of Fort Collins make the election to pay into the pool. Additionally, we can make the election on the City's behalf at no additional cost. Fees and Rate Guarantees 1. These specifications require that any fees quoted in your proposal be firm and guaranteed for a minimum of 12 months and cannot be changed by recalculation based on actual enrollment. Please indicate your agreement to this requirement. Is your organization willing to provide a multiple year guarantee or a second year cap on fees? Please specify separately for each service. Yes, a second year cap for the bundled services of 5% plus change in demographics on the service portion of the fixed costs. 2. The City is requesting that formal renewal notice for all services be received no later than four months or 120 days prior to the renewal date of the program. Please indicate your agreement to this stipulation. PacifiCare prefers to provide 60 days notice in order to allow extended claims data to mature. 3. When are fees due and what is the grace period for payment of fees under your agreement? If fees are paid subsequently, is a penalty and/or interest charge assessed? If yes, please explain in detail. The City of Fort Collins will receive two copies of the PacifiCare premium statement near the 15th of each month, the grace period is 30 days. We do not currently charge penalty or interest, however, we reserve the right to evaluate this in the future. 4. Are there any options available with respect to the grace period? If so, please explain the option(s) and any charge that is made for them. Many plan services are prepaid, therefore, PacifiCare's general policy is not to extend the grace period. 65 5. The contracts are to provide that change in fees can only be instituted on January 1. Please indicate whether your company is willing to issue master contracts reflecting this provision. Yes, PacifiCare is willing to guarantee our administrative and reinsurance fees for a 12 month period. 6. Can the individual services proposed by your company be purchased separately or are they interdependent upon each other? Please be specific and elaborate on any fee consideration. PacifiCare is not a stand alone TPA or UR administrator of services. We do, however, offer these services when bundled with our medical products. Assuming PacifiCare retains the EPO and POS coverage, the existing contract with Lincoln Reinsurance to provide PPO stop loss coverage may remain intact even if PacifiCare is not elected as the PPO administrator. it 66 Organization Issues 1. Please describe your organization addressing the following items: a. Ownership; PacifiCare Health Systems b. length of time in business; 23 years C. affiliated organizations; and Not Applicable d. include a copy of your most recent audited financial statement. Please refer to Annual Report attachment 2. Provide a statement, signed by an Officer of your company, that your firm has adequate personnel and financial resources to provide the services indicated in this Request for Proposal. "PacifiCare, one of the oldest health care companies in the state, has served the Colorado Market since 1974. Our experience of being the largest health plan in the state has been due to our superior customer service, high quality network of providers and our dedication to the highest quality medical care in Colorado. Throughout this time, we have developed a highly effective organizational structure designed to met the needs of our clients. In addition, we continually challenge ourselves to implement new technologies, improve work flows, and to measure and improve service to our clients, members, providers and community. PacifiCare, the 5th largest managed care company in the country, brings with it the financial resources of a $10 billion company. For all of these reasons and the information contained in this document, we feel that we have an exceptional ability to meet The City of Fort Collins requirements." James Swayze Vice President of Sales and Marketing 3. If applicable, indicate the location of the claims office where claims would be processed and/or member services is handled. Is a toll -free phone number available for member inquiries? What are the hours? If a toll -free phone number is not available, will you establish one at no additional charge? Include a description of your member services. Claims will be processed at PacifiCare in Englewood, Colorado. Toll -free phone numbers are available for member inquiries. EPO/POS: 1(800)877-9777 PPO: 1(800)255-1126 67 Member Service Representatives are available from 7:00 AM - 6:00 PM Monday through Friday. Functions of Member Services Representatives include: • Assisting employees in choosing PCPs • Answering employees' questions about claims • Location and phone number questions • Receive and responds to employees' complaints about providers • Can give maximum allowable charge for a particular procedure 4. Is your firm licensed in the state of Colorado (if applicable)? Please confirm that your proposal and/or plan design offered is in compliance with all federal and state laws and regulations that pertain to employee benefit programs, relevant state insurance regulations and other related laws. Please refer to State License attachment. 5. Please identify the individual responsible for the account in the event of claim disputes, service problems, etc. Chris Lawrence, Account Manager Direct line: (303)714-3463 Toll free: (800)877-6685 extension: 43463 �. Fax number: (303)714-3999 Customer Service: (800)877-9777 6. In the event the City desires employee meetings to present your proposed plan, are representatives from your company available to make presentations? If "yes", are there any additional rusts associated with these services? Yes, representatives are available to make presentations at no additional cost. 7. Do you agree that if this proposal results in your company being awarded a contract and if, in the preparation of that contract, there are inconsistencies between what was proposed and accepted versus the contract language that has been generated and executed, that any controversy arising over such discrepancy will be resolved in favor of the language contained in the proposal or correspondence relating to your proposal? Agreed 8. Are there any outstanding legal actions pending against your organization? If so, please explain the nature and current status of the action(s). No, there are not any outstanding legal actions pending against PacifiCare of Colorado. 68 Fees: Administration Medical Management Total Fees Incentive Risk Specific Stoploss Premium (lifetime max $2,000,000) Fixed Costs Estimated Capitation Estimated Claims Estimated Claims & Capitation Annual Expected Claims Specific Stop loss limit Enrollment Assumption 7/28/0" City of Fort Collins Effective Date 01 /01 /99 EPO - Paid Reinsurance Contract EE EE+S EE+Ch(ren) Family POS - Paid Reinsurance Contract EE EE+Sp EE+Ch(ren) Family $8.04 $17.67 $20.09 $27.32 $8.10 $17.82 $20.25 $27.54 $5.77 $12.70 $14.43 $19.62 $5.82 $12.80 $14.54 $19.78 $13.81 $30.37 $34.52 $46.94 $13.92 $30.62 $34.79 $47.32 $2.46 $5.41 $6.15 $8.36 $2.46 $5.41 $6.15 $8.36 $3.43 $7.55 $8.40 $11.66 $3.60 $7.92 $8.82 $12.24 $19.70 $43.34 $49.07 $66.97 $19.98 $43.95 $49.76 $67.92 $27.79 $61.14 $68.09 $94.49 $33.43 $73.55 $81.90 $113.66 $94.68 $208.30 $238.10 $321.93 $117.76 $259.08 $296.08 $400.40 $122.47 $269.44 $306.19 $416.41 $151.19 $332.63 $377.99 $514.06 $2,175,727 $306,623 $135,000 $135,000 215 107 106 225 27 10 14 25 9. Please state the time line your company intends to follow to commence work as of January 1, 1999. Once the District has made their decision, PacifiCare staff will work with the group to determine open enrollment needs and tentative dates. An implementation table would look something like the following: Completion Date Implementation Steps Responsibility Insurance Committee Decision iTity of Fort Collins October 9, 1998 - Development of Open Enrollment Chris Lawrence October 13, 1998 Materials Assessment of Customized Needs Schedule Open Enrollment Late October, 1998 Open Enrollment Meetings Chris Lawrence December 7, 1998 Receipt of Enrollment Forms, Chris Lawrence December 21, 1998 Completed Summary Plan Documents Chris Lawrence December 7, 1998 - Enter Enrollment Data Jeff Green December 11, 1998 December 18, 1998 Mail ID Cards Scott Lane Benefit literature and other communication materials will be available in draft form 30 days after receipt of enrollment forms. n 10. What is your perspective on the health care industry in five years? What changes do you foresee? Managed Health Care is starting to see providers assuming more risk, therefore participating more actively in Medical Management decisions. PacifiCare believes drug trends wi'n continue to escalate. Some contributing factors include: • consumer advertising • breakthrough therapies • decreased competition in the generic drug market. Specifically in the Fort Collins area, as we have discussed, hospitals are aggresively pursuing contracts directly with employers. PacifiCare thinks this will negatively impact the employers options regarding insurance carriers. 11. If you have obtained national accreditation, please state through which agency and when it was obtained. A full three year accreditation was obtained through NCQA as of September, 1997. 69 Cigl of Fort Collins Proposal to Provide Medical Benefits • ATTACHMENTS Network Service Area A Sample Utilization Reports B Managed Care Services C Provider Directory D GEO Access E Disruption Analysis F UM Program Description G QI Program Description H Sample Per Member Utilization Report I Physician Profiling Sample j Pre -Service Review K Appeal Process L PPO Benefit Summary M Sample Performance Guarantees N Annual Report O State License P July 29, 1998 PacffiCares No Text No Text No Text Sample HMO Sherlock Report ABC COMPANY COMPANY NUMBER ABC00 01 /01 /96 - 12/31 /96 HMO MEDICAL EXPERIENCE Contents 1 Introduction . . . . . . . . . . . . . . . . . . . 1 2 Explanation Of Terms . . . . . . . . . . . . . . . 2 3 Overview . . . . . . . . . . . . . . . . . . . . . 3 4 Membership Demographics . . . . . . . . . . . . . . 4 5 Member Relationship Analysis . . . . . . . . . . . 5 6 Member Age Analysis . . . . . . . . . . . . . . . . 6 7 Paid Claims By Cause . . . . . . . . . . . . . . . 7 8 Provider Information . . . . . . . . . . . . . . . 8 9 Provider And Vendor Discount Savings . . . . . . . 9 10 Payments By Benefit Category . . . . . . . . . . 10 11 Inpatient Utilization . . . . . . . . . . . . . . 11 12 Catastrophic Illness . . . . . . . . . . . . . 12 13 Analysis Of Circulatory System . . . . . . . . . 13 14 Analysis Of Injury & Poisoning . . . . . . . . . 14 15 Analysis Of Pregnancy & Childbirth . . . . . . . 15 16 Analysis Of Digestive System . . . . . . . . . . 16 17 Analysis Of Skeleton & Muscle System . . . . . . 17 18 Analysis Of Tumors . . . . . . . . . . . . . . . 18 01 /01 /96 - 12/31 /96 ABC COMPANY ABC00 Page 1 Introduction PacifiCare is pleased to provide you with this comprehensive reporting package which focuses on your HMO coverage. The intent is to provide an array of reports which help to explain the impact of our medical management services. Under the HMO, medical benefits are paid for in two ways: ■ Capitation - a method of pre -paying for designated medical services. ■ Negotiated fee arrangements - providers are reimbursed a specific fee for a given medical service. These are referred to as "Paid Claims" throughout this document. This reporting package analyzes total medical payments (claims plus capitation) for your members. The package then provides a detailed analysis of the services provided under fee arrangements ("Paid Claims"). Overall, 49% of your HMO expenses were paid claims. At PacifiCare, we turn data into useful information to assist you in making informed decisions about your benefit plan. n 1 /01 /96 - 12/31 /96 ABC COMPANY ABC00 Page 2 Explanation Of Terms ■ Members - All eligible persons, including employees and their covered dependents, spouses, and retirees. ■ PMPM - Per Member, Per Month. A monthly expense per member is calculated by dividing total expenses by cumulative member months. ■ Days - The number of inpatient days. ■ ALOS - Average Length of Stay. ■ Days per 1000 and Admissions per 1000 - The number of days/admissions per 1000 covered members. These indicies are HMO standards for measuring utilization. ■ ICD-9 Code - International coding scheme used to reflect physician diagnosis (International Classification of Diseases, 9th Revision). ■ Cause - Groupings of diagnostic categories (ICD-9 codes) which identify bodily systems. ■ Claimants - Members with referral claims that were not covered through capitated HMO services. ■ Admits - Number of admissions to an inpatient healthcare facility. 01 /01 /96 - 12/31 /96 ABC COMPANY ABC00 Page 3 Overview ■ This analysis contains paid claims and capitation expenses. ■ The total expenses were $3,602,209. ■ The total capitation expenses were $1,845,811, which covered these types of services: - PRIMARY CARE PHYSICIAN - MENTAL HEALTH - VISION - RADIOLOGY -LABORATORY - PHYSICAL THERAPY -OTHER ■ Medical paid claims totaled $1,756,398. Of this amount, Employees accounted for $1,303,735. Spouses accounted for $144,345. Children accounted for $308,318. - Claims associated with inpatient admissions were $613,232 (35%) - Outpatient care expenses were $571,509 (33%). - Pharmacy expenses were $571,657 (33%). ■ There were a total savings resulting from Coordination of Benefits of $3,175. These savings were not reflected in the paid amounts of this report where the data is categorized by benefit category or specific CPT4 codes. ■ There were a total of 126 inpatient admissions to healthcare facilities, totaling 449 days. The period covered was January 1, 1996 through December 31, 1996 and only claims and capitation paid in that period were considered. This report was processed on September 24, 1997. City of Ft Collins 1999 PROSPECTIVE RATE Combined HMO / POS PAID CLAIMS Paid Claims (07/01/97 - 06/30/98) $1,419,701 Less Claims over $135,000 $0 Adjusted Paid Claims $1,419,701 / Employee Months (05/01 /97 to 03/31 /98) $7,352 = Paid Claims PEPM $193.10 x Trend (blended all sublines) 1.0944 Expected Future Claims $211.34 CAPITATION Paid Capitation (07/01/97 - 06/30/98) $471,070 /Employee Months (07/01/97 - 06/30/98) $7,623 = Capitation PEPM $61.80 x Trend (blended all sublines) 1.0453 = Expected Future Capitation $64.60 Expected Claims Plus Capitation $275.94 x Adjustment for Prior Year Plan Change 1.000 = Adjusted Expected Claims and Capitation $275.94 Manual Claims PEPM $324.39 Credibility (blended) $284.98 Current Expected Claims PEPM $271.10 Projected Increase 5.12% 7/27/98 1 /01 /96 - 12/31 /96 ABC COMPANY ABC00 Membership Demographics Members by Relationship and Age Bands: Age Band Less than 1 1-19 20-34 35-49 50-64 65 and over Total Members by Sex and Age Bands: Females: Employee Spouse Children Total 0 0 30 30 6 1 926 933 431 32 82 544 1,014 119 0 1,133 506 89 0 595 16 0 0 16 1,973 241 1,038 3,251 AgeBand Percent Members of Total Less than 1 13 0.4% 1-19 459 14.1% 20-34 346 10.6% 35-49 736 22.6% 50-64 358 11.0% 65 and over 10 0.3% Total Females 1,920 59.1% Males: Less than 1 18 0.5% 1-19 474 14.6% 20-34 198 6.1% 35-49 397 12.2% 50-64 237 7.3% 65 and over 7 0.2% Total Males 1,331 40.9% Overall 3,251 100.0% Page 4 01 /01 /96 - 12/31 /96 ABC COMPANY ABC00 PAID CLAIMS AND CAPITATION Member Relationship Analysis The distribution of medical expense (including capitation) by Relationship (Employee active or retired, Spouse, and Children) compared to PacifiCare experience was: Employees PacifiCare Regional Norms 52% Client 73% Total Expenses: Capitation Paid Claims Paid Total Expense Member Averages: Average Members Avg. PMPM Expense Employees Spouses Spouses Children 26% 21% 8% 19% Children Total $1,312,422 $155,242 $378,146 $1,845,811 $1,303,735 ------------------------------------------------------------ $144,345 $308,318 $1,756,398 $2,616,157 $299,587 $686,465 $3,602,209 Inpatient Experience: Inpatient Admissions Inpatient Days Admits per 1000 Members (Annualized) Days per 1000 Members (Annualized) 1,973 241 1,038 3,251 $110.53 $103.74 $55.11 $92.33 87 14 25 126 366 31 52 449 44 58 24 39 186 129 50 138 Page 5 01 /01 /96 - 12/31 /96 ABC COMPANY ABC00 Member Age Analysis Page 6 This analysis looks at the ages of the members and claimants. The ages were calculated as of the end of the period, so only a single age is assumed for the entire period. Average Age by Relationship: Relationship Average Claimant Age Average Member Age Employee 45.8 years old 44.9 years old Spouses 47.7 years old 47.5 years old Children 12.6 years old 11.8 years old Average Age 40.1 years old 34.6 years old The regional average claimant age for PacifiCare is approximately 39.5 years old. Experience by Sex and Age Bands: Paid Capitation Combined Age8and Members Claims Total PMPM Females: Less than 1 13 9,002 12,458 143.07 1-19 459 104,886 160,282 48.14 20-34 346 194,882 235,124 103.52 35-49 736 347,279 534,398 99.87 50-64 358 305,603 284,625 137.58 65 and over 10 12,648 7,975 180.91 Total Females 1,920 $974,301 $1,234,863 $95.87 Males: Less than 1 18 15,922 18,948 163.71 1-19 474 134,032 154,465 50.71 20-34 198 72,457 71,381 60.46 35-49 397 252,394 193,116 93.54 50-64 237 302,044 166,660 164.75 65 and over 7 5,249 6,377 145.32 Total Males 1,331 $782,098 $610,948 $87.23 Overall 3,251 $1,756,398 S1,845,811 $92.33 n 1 /01 /96 - 12/31 /96 ABC COMPANY ABC00 Page 7 PAID CLAIMS ONLY (NO CAPITATION) Paid Claims By Cause The following table illustrates the paid claims by Cause (ICD-9 grouping). Here the claimant count increases to show the claimants by ICD-9 codes. Paid Claims (both inpatient and outpatient, excluding pharmacy) for this period were as follows: Paid % of % of Cause Claims Paid Days Days Claimants Circulatory System 190,745 16.1 131 29.2 40 Injury & Poisoning 171,860 14.5 25 5.6 239 Pregnancy & Childbirth 121,587 10.3 85 18.9 134 Digestive System 120,661 10.2 48 10.7 79 Skeleton & Muscle System 104,712 8.8 16 3.6 136 Tumors 95,380 8.1 58 12.9 78 Genitourinary System 69,951 5.9 15 3.3 90 Symptoms & Signs 69,529 5.9 11 2.4 187 At( Others/Supplementary 46,726 3.9 15 3.3 36 Glands & Metabolism 45,869 3.9 5 1.1 14 Respiratory System 42,144 3.6 15 3.3 86 Nervous Sys/Sense Organs 26,725 2.3 0 0.0 59 Skin & Skin Related 25,441 2.1 V 2.2 19 Infections & Parasitic 24,882 2.1 8 1.8 36 Birth Defects 22,445 1.9 3 0.7 13 Perinatal Conditions 4,240 0.4 4 0.9 10 Blood Related 1,650 0.1 0 0.0 5 Mental & substance Abuse 193 0.0 0 0.0 5 Total 51,184,741 449 1,266 The leading individual (medical) ICD-9 diagnoses were: Paid % of % of ICD-9 Diagnosis Claims Paid Days Days Claimants 410 MYOCARD INFARCTION AC 60,268 5.1 12 2.7 3 844 SPRAIN KNEE 45,503 3.8 1 0.2 22 414 ISCHEMIC HRT DISCHRON 39,895 3.4 45 10.0 11 V57 REHABILITATION PROC N 38,483 3.2 15 3.3 3 218 UTER LEIOMYOMA 34,080 2.9 27 6.0 11 253 PITUITARY/HYPOTHALM D 33,022 2.8 0 0.0 1 574 CHOLELITHIASIS 30,120 2.5 11 2.4 10 560 INTEST OSTRU W/O HERN 25,719 2.2 19 4.2 4 196 CA LYMPH NODES SECOND 25,550 2.2 19 4.2 1 717 KNEE INT DERANGEMENT 24,028 2.0 0 0.0 18 0 1 /01 /96 - 12/31 /96 ABC COMPANY ABC00 Provider Information Claim payments went to the following recipients: Paid % of Claims Paid Paid Directly to Hospitals $1,059,599 60.3 Paid to Non -Hospital Providers $694,595 39.5 Paid to Insured $2,204 0.1 The leading hospital providers for this time frame were: (* denotes an PacifiCare Preferred or Network Provider) Paid Provider Name City State Days Claims *BOULDER COMM HOSP-INPATIENT BOULDER CO 247 369,242 *BOULDER COMM HOSP-OUTPATIENT BOULDER CO 4 180,278 *AVISTA HOSPITAL -OUTPATIENT LOUISVILLE CO 0 74,525 *AVISTA HOSPITAL -INPATIENT LOUISVILLE CO 66 68,050 *BOULDER MED CENTER -SURGICAL BOULDER CO 0 56,417 *LONGMONT UNITED -OUTPATIENT LONGMONT CO 0 27,914 *MAPLETON CTR/REHAB-IP/BOULDER BOULDER CO 39 27,300 *ST ANTHONY CENTRAL -INPATIENT DENVER CO 21 22,490 *LONGMONT UNITED -INPATIENT LONGMONT CO 15 21,441 *ST ANTHONY NORTH -INPATIENT WESTMINSTER CO 17 19,020 LUTHERAN HOSP - INPATIENT WHEAT RIDGE CO 4 18,222 *CHILDREN'S HOSP-OUTPATIENT DENVER Co 0 14,743 *ST ANTHONY CENTRAL -OUTPATIENT DENVER CO 0 14,239 *ST ANTHONY NORTH -OUTPATIENT WESTMINSTER CO 0 13,373 *NORTH CO RED CTR - 1P GREELEY CO 9 12,805 *POUDRE VALLEY HOSPITAL - OP FORT COLLINS CO 0 9,359 SWEDISH MEDICAL CENTER - OP ENGLEWOOD CO 0 8,623 *AVISTA MEDICAL CENTER - X-RAY LOUISVILLE CO 0 8,190 *P/SL MEDICAL CENTER - INPT DENVER CO 6 7,150 *ROSE MEDICAL CENTER - INPT DENVER CO 6 6,274 *MCKEE MEDICAL CTR-INPATIENT LOVELAND CO 3 5,370 *PORTER CARE HOSPITAL - OUTPT DENVER CO 0 5,232 *ROCKY MTN LITHOTRIPSY LTD DENVER CO 0 4,628 VERDUGO HILLS HOSPITAL GLENDALE CA 3 4,535 *MCKEE MEDICAL CTR-OUTPATIENT LOVELAND CO 0 4,270 Page e n 1 /01 /96 - 12/31 /96 ABC COMPANY ABC00 The leading non -hospital providers were: Provider Name *APRIA - INFUSION *APRIA HEALTHCARE *WESTERN HOME CARE *AMR OF COLORADO - DENVER *ROCCI TRUMPER MD *MARK DOUTHIT MD *AMR OF COLORADO-COMM/SNR PLN BROOMFIELD EMERG AMBULANCE *TOKOS CLINICAL SVCS CORP STEPHEN J WEDDEL MD PC Provider And Vendor Discount Savings Paid City State Days Claims LITTLETON CO 0 34,389 LITTLETON CO 0 8,540 ARVADA CO 0 7,627 DENVER CO 0 4,418 FORT COLLINS CO 0 4,198 GREELEY CO 0 3,774 DENVER CO 0 3,344 DENVER CO 0 2,454 DENVER CO 0 1,930 LONGMONT CO 0 1,776 Page 9 The savings from Provider and Vendor Discounts amounted to $563,003 and the details are as follows: --------------------- Network --------------------- Category Charged Allowed Savings Hospital Facility 1,456,941.12 940,971.47 515,969.65 Physician Service 191,634.62 159,309.24 32,325.38 Other 56,168.87 41,461.28 14,707.59 TOTALS $1,704,744.61 $1,141,741.99 $563,002.62 -- Non -Network Category Charged Hospital Facility 46,663.90 Physician Service 31,893.21 Other 9,887.00 TOTALS $88,444.11 Overall percentage savings for in -network client charges were 33.0%, and 95.1 % of charges were from network providers. nl/01/96 - 12/31 /96 ABC COMPANY ABC00 Payments By Benefit Category The medical payments by benefit category during this period were: Hospital Expense Pharmacy Medical Care Miscellaneous Surgery X-Ray & Lab Anesthesia Unknown Emergency Care Vision Coordination of Benefits Paid % of PacifiCare Amount Paid Norm 1,027,060 58.5 59.7 579,621 33.0 25.2 75,965 4.3 7.4 33,437 1.9 4.1 20,055 1.1 4.2 13,511 0.8 3.1 6,062 0.3 1.9 1,912 0.1 0.0 1,888 0.1 0.3 62 0.0 0.0 -3,175 -0.2 0.0 Page 10 n 1 /01 /96 - 12/31 /96 ABC COMPANY ABC00 Page 11 Inpatient Utilization The total number of inpatient admissions in this period was 126, and totaled 449 days Due to the medical management of the HMO Utilization Review program, unnecessary hospital confinements have been eliminated. Because of this, HMO patients admitted to hospitals tend to be sicker, and appear to consume more services and incur longer lengths of stay. However, overall days and admissions per 1000 members are lower than non -HMO experience. Admission Statistics Regional Client HMO Total Admissions 126 Total Days 449 Average length of stay 4 4 Admissions per 1000 members 39 47 Days per 1000 members 138 191 Average admission paid total $4,808 $5,451 Average daily paid $1,349 51,349 Admission Total Paid Analysis Total Hospital Average $4,662 $5,459 Professional Fees Average $81 $322 Other Expense Average $65 S-330 The paid amounts in this section do not reflect any savings from Coordination of Benefits: Admission Type Admissions Days ALOS Ave S/Ado Ave S/Day Medical 84 351 4.2 5,718 1,368 Surgical 3 13 4.3 9,959 2,298 Pregnancy - Normal Delivery 27 34 1.3 1,427 1,133 - Cesarean Section 6 32 5.3 7,416 1,390 - Newborn 6 19 3.2 2,098 662 Mental - Psych 0 0 0.0 0 0 - Substance Abuse 0 0 0.0 0 0 n 1 /01 /96 - 12/31 /96 ABC COMPANY ABC00 Page 12 Catastrophic Illness A catastrophic illness is defined as paid amounts in excess of $25,000 to a single individual for a single cause. Catastrophic illnesses totaled $224,370, or 12.8% of medical claims. This total was incurred by 6 claimants, or 0.0% of the total. The PacifiCare regional norms are about 15.2% of the claims caused by about 0.0% of the claimants. The average paid per claimant was $37,395. The average PacifiCare catastrophic claim was $53,055. Catastrophic Illness Cases by Diagnostic Category: Average Paid Cause Claimants Days Payment per Claimant Circulatory System 3 105 125,876 41,959 Glands & Metabolism 1 0 36,402 36,402 All Others/Supplementary 1 15 36,100 36,100 Tumors 1 19 25,992 25,992 Total 6 139 $224,370 $37,395 Catastrophic Illness Cases by Relationship: Average Paid Relationship Claimants Days Payment per Claimant Employees 5 139 187,968 37,594 Children 1 0 36,402 36,402 Catastrophic Illness Cases by Age Band: Average Paid Age Band Claimants Days Payment per Claimant 1-19 1 0 36,402 36,402 35-49 2 20 71,083 35,542 50-64 3 119 116,885 38,962 n 1 /01 /96 - 12/31 /96 ABC COMPANY ABC00 Analysis Of Circulatory System Page 13 Circulatory System claims accounted for 16.1 % of the payments in this period, and 3.2% of the claimants. Relationship Employees Spouses Total Age Band 20-34 35-49 50-64 65 and over Leading Diagnosis 410 MYOCARD INFARCTION ACUTE 414 ISCHEMIC HRT DISCHRONIC 436 CVD ACUTE 433 OCCLUSIN/STENOSIS OF ART 431 INTRACERE HEMORRHAGE 434 OCCLUS'N CEREBRAL ARTERI 432 INTRACRAN HEMORRHAGE OTH 454 VARI VEIN LEG 411 ISCHEMIC HRT DISEASE ACU 453 EMBOL/THROMBOSIS OTHER V Admission Type Medical Surgical Total Claimants Days 36 127 4 4 40 131 Claimants Days 2 0 13 20 23 105 2 6 Claimants Days 3 12 11 45 1 27 1 19 1 11 1 7 1 4 1 0 1 3 1 0 Average Paid Payment per Claimant 183,151 5,088 7,594 1,898 5190,745 54,769 Payment Ave Paid 285 142 83,823 6,448 99,931 4,345 6,706 3,353 Payment Ave Paid 60,268 20,089 39,895 3,627 18,076 18,076 17,776 17,776 11,990 11,990 7,565 7,565 6,718 6,718 6,140 6,140 5,340 5,340 4,485 4,485 Admits ALOS Ave Paid Ave/Day 10 12.4 18,526 1,494 1 7.0 20,038 2,863 11 11.9 18,663 1,567