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7 Cards in this Set
- Front
- Back
Kong 37
Electronic Commerce In Managed Health Care |
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Why the Health Care Sector Needs E-Commerce
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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. |
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Types of E-Commerce Technologies:
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The Internet
Intranet Interactive Voice Response (IVR) Imaging and OCR Electronic Funds Transfer (EFT) Electronic Data Interchange |
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Four Levels of E-Commerce Functionality
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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 |
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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 |
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to the MCO Itself
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Storing information about proposals
Keep an up-to-date plan policy manual provider contract database medical protocols automated underwriting and rerating claims adjudication |
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DIFFICULTIES IN USING E-COMMERCE
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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. |