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7 Cards in this Set

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  • Back
Kong 37
Electronic Commerce In Managed Health Care
Blank
Why the Health Care Sector Needs E-Commerce
 HIPAA is imposing data standards
 Premium Compression and Price Parity
 service and quality are the main differentiators
 Physicians and Patients techknowledgable.
 Stock analysts rate MCO’s with e-commerce better.
Types of E-Commerce Technologies:
 The Internet
 Intranet
 Interactive Voice Response (IVR)
 Imaging and OCR
 Electronic Funds Transfer (EFT)
 Electronic Data Interchange
Four Levels of E-Commerce Functionality
 Static (simplest)
 a fixed list of information
 company information
 participating providers
 basic health and wellness information
 All MCO’s have this.

 Interactive
 simple personal transactions
 changing PCP online
 requesting a new ID card.
 still handled by customer service people. Not truly automated.

 Semi-Integrated
 complex personal transactions handled by the computer
 check claim status
 providers can submit an authorization
 check eligibility

 Integrated
 enrolling a group
 electronic claims forms
 paying providers
 online appointments
 exchange of medical notes between PCP and SCP
USES AND BENEFITS OF E-COMMERCE
to the MCO’s External Customers
for Employers
 check eligibility of ee’s
 see cost and utilization data

Benefits:
 Lets Er develop better flex plan options.

for Employees
 change provider information
 check claim status
 refill a prescription

Benefits:
 not limited to customer service hours
 no delays

for Providers
 get authorizations and referrals
 claim submissions
 see copay / eligibility info
 links to pharmacies and formularies

Benefits:
 reduced need for staff

for Agents / Brokers
 proposal generation and product pricing.
 direct marketing
 Online UW and quotes

Benefits:
 Improves delivery scope and speed
to the MCO Itself
 Storing information about proposals
 Keep an up-to-date plan policy manual
 provider contract database
 medical protocols
 automated underwriting and rerating
 claims adjudication
DIFFICULTIES IN USING E-COMMERCE
 Expensive
 small MCOs must hire out
 no clear leader in E-commerce
 Hard to determine costs/benefits of adopting e-commerce
 Internet transactions are not standardized
 The Internet is largely unregulated
 MCO could post wrong information
 doctors e-mail noncompliant advice
 Privacy issues
 MCO’s have “legacy systems”
 hard to replace them with e-commerce.
 The MCO’s deficiencies become public
 National and local MCO’s have different e-commerce needs

Done.