How InterQual® Software Improves the Financial Health of the Critical Access Hospital

Eboney White

Sr. Product Consultant

Dena Heyman

Sr. Sales Executive

June 15, 2015

2

Demands on Healthcare are Driving Change

RehabFacility

Patient’sHome

Payer

Hospitals& HealthSystems

PhysicianOffice

Pharmacy

Increased costof care & declining

reimbursements

MeaningfulUse

ICD-10ARRA

PPACA

New modelsfocused on

care coordination

Increasing volumes& acuity of patients

Interoperability& information

exchange Physicianalignment

Ongoingclinician

shortages

New &evolving payment

models

Patient engagement

Hospital CFOs: Top 10 Challenges

Med

icare

redu

ctio

ns

Declin

ing

or fl

at IP

vol

umes

Med

icaid

redu

ctio

ns

Incr

easin

g op

erat

ing

cost

s

Bad d

ebt

Payer

neg

otia

tions

RAC/oth

er a

udits

Other

Reven

ue c

ycle

Inve

stm

ents

/cap

ital

0

10

20

30

40

Source: B. Herman, “The State of Healthcare Finance: 9 Major Survey Findings From Hospital CFOs,” Becker’s Hospital Review, February 6, 2014

No. of Responses

InterQual® and the Critical Access Hospital

InterQual® Clinical Content1. Gold Standard Evidenced Based Medicine 2. Influence Claims Submission Patterns and Outcomes3. Request Reimbursement and File Appeals with Confidence

CareEnhance Review Manager Enterprise4. Increase Revenue Stream5. Better Financial Support Documentation6. Reduce Bad Debt7. Streamline Case Review for Denials8. Gain insight for Process Improvement and Financial Gain

5Copyright © 2015 McKesson Corporation and/or one of its subsidiaries. Confidential and proprietary.

Our Community

6

Clinical Content Development Expertise38+ Years of Experience

Content Development

Critical Apprai

sal

Authoritative Review

Content

Validation

QA/Release

InterQualEvidence-Based

Content

1

2

3

4

51. Identification of content for new

development and updates

2. Critical appraisal of the literature and development of content based on the best available medical evidence

3. Authoritative review of the content by an independent clinical panel of experts

4. Internal consensus, finalization of the content, and second independent clinical review

5. Quality assurance review of the content and software prior to general availability

Copyright © 2015 McKesson Corporation and/or one of its subsidiaries. Confidential and proprietary.

7Copyright © 2015 McKesson Corporation and/or one of its subsidiaries. Confidential and proprietary.

InterQual Evidence-Based Content

• Procedures

• Imaging

• Durable Med Equip

• Molecular Diagnostics

• Specialty Rx Non-Onc

• Specialty Rx Onc

• Specialty Referral

• SIMplus™

• Acute Adult

• Acute Pediatric

• Long Term Acute Care

• Acute Rehabilitation

• SAC / SNF

• Home Care

• Outpatient Rehab and Chiropractic

• Geriatric Psychiatry

• Adult Psychiatry

• Adolescent Psychiatry

• Child Psychiatry• Substance Use

Disorders and Dual Diagnosis

• Residential and Community Based Treatment

• Coordinated Care Content

Care Planning Level of Care Behavioral Health Care Management

Spanning the Continuum of Care

Pre-AuthorizationAcute and Post

Acute Settings of Care

Behavioral HealthComplex Case and

Disease Management

8

Case Study

42-year-old male presenting to ED for dull RUQ pain

Should he be admitted? Should he have an open or laparoscopic cholecystectomy ($9,768)? Does he get

admitted for observation ($1741) or acute ($5,142) while we wait for imaging?

Re-admitted to the hospital 8 days after elective laparoscopic cholecystectomy for gallstones because

of dull right upper quadrant (RUQ) pain that increased with meals. Physical examination disclosed no

abnormalities except for mild RUQ tenderness and fever (100.0 °F, 37 °C).

Should we do an US ($154)? CT ($536)? MRI ($546)? HIDA Scan ($767)?

What is the cause of multiple inconclusive diagnostics?

Are we going to get reimbursed? Are we going to get denied?

The Case for Clinical Decision Support

*All Prices from Healthcare Bluebook.

9

On Average, Medicare Paid Nearly Three Times More for a Short Inpatient Stay Than an Observation Stay and

Beneficiaries Paid Almost Two Times More

In total, Medicare paid $5.9 billion for short inpatient stays, an average of $5,142 per stay.

In contrast, it paid $2.6 billion for observation stays, an average of $1,741 per stay.

Clinical Decision Support Helps to Get it Right the First Time

Source: Memorandum Report: Hospitals' Use of Observation Stays and Short Inpatient Stays for Medicare Beneficiaries , OEI-02-12-00040

10

Demonstration

11

Q & A

12Copyright © 2015 McKesson Corporation and/or one of its subsidiaries. Confidential and proprietary.

Additional Offerings

• Ensure consistency and appropriate application of content• Identify educational opportunities

Inter-Rater Reliability

• Standard, super-user, and physician programs• InterQual Certified Instructor

InterQual Training

• Edit or modify InterQual content• Create new content

InterQual Content Customization Tool

• Shareable access to content

InterQual Transparency Tool

13Copyright © 2015 McKesson Corporation and/or one of its subsidiaries. Confidential and proprietary.

Technology OptionsSimple to Robust

• InterQual® Mobile

• IQ View

• IQ Online• CareEnhance ®

Review Manager

• Clear Coverage™

View Only Interactive Workflow Auto Authorization