PM
Perform Provider Outreach
Provider Support
Description
The Perform Provider Outreach business process originates internally within the State Medicaid Agency (SMA) in response to multiple activities (e.g., identified gaps in medical service coverage, public health alerts, provider complaints, medical breakthroughs, modifications in the Medicaid Program policies and procedures). SMA may develop prospective Provider outreach information, also referred to as Provider Recruiting information, for targeted providers identified by analyzing program information (for example, not enough dentists to serve a population, new immigrants need language-compatible providers). Enrolled Provider outreach information may relate to corrections in billing practices, public health alerts, public service announcements, drive to sign up more Primary Care Physicians, and other objectives. The State Medicaid Agency develops outreach information for target populations identified by analyzing member information. The State Medicaid Agency may communicate information in a variety of methods such as email, mail, publication, mobile device, facsimile, telephone, web or Electronic Data Interchange (EDI). The State Medicaid Agency produces, distributes, tracks and archives all contractor outreach communications according to state rules. The Manage Performance Measures business process defines benchmarks and measures outreach efficacy. NOTE: The Perform Provider Outreach business process targets both prospective and current provider populations for distribution of information about programs, policies, and health issues. Manage Provider Communication business process handles inquiry from applicants, prospective and current providers by providing assistance and responses to individuals (i.e., bi-directional communication).
Business Process Template
Trigger events
Environment-based
- Executive Management decision to: o Fill gaps in health care service and administrative coverage. o Solicit updated/new administrative and technical functions. o Introduce new programs requiring new types of health or administrative service. o Change existing policies and procedures. o Identify critical need for a specific target population. o Identify new populations in need of service (e.g., new immigrant communities).
Interaction-based
None published
Results
- Agency produces outreach communications (e.g., mailing brochures, web pages, email, kiosk, and radio, billboard, and TV advertisements) and distributes to targeted providers. Agency may also conduct face-to-face meetings.
- Tracking information as needed for measuring performance and business activity monitoring.
Business process steps
- 1. START: Receive request for outreach materials or communication.
- 2. Target population is identified and defined by analyzing information, performance measures, feedback from community, and policy directives.
- 3. Approve, deny, or modify decisions to develop outreach communications.
- 4. Determine content and method of communication (e.g., email, mail, publication, mobile device, facsimile, telephone, web or EDI.
- 5. Determine performance measures.
- 6. Prepare content that is linguistically, culturally, and competency appropriate for the communication in agreed upon format.
- 7. Review and approve communication.
- 8. Generate communication in agreed upon format.
- 9. Agency logs communication message.
- 10. END: Evaluate the efficacy of the communication (e.g., customer satisfaction, first time resolution rate)
Predecessor processes
Successor processes
- Send Outbound Transaction
- Manage Provider Communication
Shared data
- Provider data store including provider network, application and enrollment information
- Plan data store including policy information
- Health Benefits data store including benefit package and benefit information
- Performance Measures data store including agency’s objectives
- Care Management data store including population health and treatment plan information
- Business activity data store including performance information
- Compliance Management data store including compliance incident information
Constraints
Communications and information packages will address the needs of the targeted population. Materials will be linguistically and culturally appropriate, legally compliant, appropriate to the targeted group, and meet financial guidelines (re: cost to produce and distribute). Other constraints may be agency priority, availability of resources, and accuracy of contractor contact information. Provider may have communication barriers such as lack of Internet or phone access. Provider is unable to access needed or requested information.
Failures
- Unable to identify target population based on desired criteria.
- Management denies permission for outreach activity.
- Cancel health plan or health benefit.
- Delivery failures due to erroneous contact information.
Performance measures
- Time to complete process of developing outreach materials = __ days
- Accuracy of outreach materials = __%
- Successful delivery rate to targeted individuals = ___%
- Effectiveness of the communication - Outreach results in achieving specified goals (e.g., recruitment of new providers from targeted population)
Source: CMS MITA 3.0 Business Process Template, Provider Management BPT.pdf, pages 11-13.
Business Capability Model (12 questions)
Each capability question defines five maturity levels, from Level 1 through Level 5.
Business Capability Descriptions
Is the process manual or automatic?
- LEVEL 1The process consists primarily of manual activity to accomplish tasks. SMA primarily conducts the process via mail, in person and telephone for individual communications; and flyers, radio, TV, newspapers, and publications for public media. At this level, there is no targeting of providers.
- LEVEL 2SMA uses a mix of manual and automatic processes to accomplish tasks. SMA conducts process via a web portal for existing providers. SMA target populations to receive communications via mail, in person and telephone for individual communications; and flyers, radio, TV, newspapers, and publications public media.
- LEVEL 3SMA automates process to the full extent possible within the state. The process is electronic. Audience downloads, saves or prints publications. Portal includes usability features or functions that accommodate the needs of persons with disabilities, including those who use assistive technology.
- LEVEL 4SMA automates process to the full extent possible within the region.
- LEVEL 5SMA automates process to the full extent possible across the nation.
Is communication linguistically, culturally, and competency appropriate?
- LEVEL 1Functionally, linguistically, culturally, and competency appropriate outreach and education materials are lacking because they are difficult and costly to produce.
- LEVEL 2Outreach material is functionally, linguistically, culturally, and competency appropriate, but at great expense. SMA limits outreach material by state defined parameters (e.g., only two (2) languages used).
- LEVEL 3SMA automates process to the full extent possible across the intrastate. Use of electronic communications makes provision of functionally, linguistically, culturally, and competency appropriate outreach material more cost-effective.
- LEVEL 4SMA automates process to the full extent possible within the region.
- LEVEL 5SMA automates process to the full extent possible across the nation.
Does the State Medicaid Agency use standards in the process?
- LEVEL 1SMA focuses on meeting compliance thresholds for state and federal regulations using state-specific standards.
- LEVEL 2SMA applies a mix of HIPAA and state-specific standards.
- LEVEL 3SMA adopts MITA Framework, industry standards, and other nationally recognized standards for intrastate exchange of information.
- LEVEL 4SMA adopts MITA Framework, industry standards, and other nationally recognized standards for clinical and interstate information exchange of information within the region.
- LEVEL 5SMA adopts MITA Framework, industry standards, and other nationally recognized standards for national exchange of information.
How formalized is the process?
- LEVEL 1The process is informal and inconsistent.
- LEVEL 2The process is formal across SMA with proper reviews to ensure correctness and legality. SMA keeps accurate logs kept of all outreach initiatives.
- LEVEL 3SMA adopts automatic workflow within the intrastate to ensure accuracy and proper reviews. SMA transfers and stores the documents electronically.
- LEVEL 4SMA adopts automatic workflow within the region to ensure accuracy and proper reviews.
- LEVEL 5SMA adopts national automatic workflow to ensure accuracy and proper reviews.
How does the State Medicaid Agency collaborate with other agencies or entities in performing the process?
- LEVEL 1Very little collaboration occurs with other agencies to standardize information exchange or business tasks.
- LEVEL 2SMA collaborates with other agencies and entities to adopt HIPAA standards and Electronic Data Interchange (EDI) transactions.
- LEVEL 3SMA collaborates with other intrastate agencies and entities to adopt national standards, and to develop and share reusable business services.
- LEVEL 4SMA collaborates with other regional agencies and entities to adopt national standards, and to develop and share reusable processes including clinical information.
- LEVEL 5SMA collaborates with federal agencies and entities for national (and international) interoperability improvements that maximize automation of routine operations.
Business Capability Quality: Timeliness of Process
How timely is the end-to-end process?
- LEVEL 1Process meets threshold or mandated requirements for timeliness (i.e., the process achieves results within the time specified by law or regulation). Timeliness depends on the type of outreach. It is ad hoc in nature. Outreach activity duration is relatively lengthy.
- LEVEL 2Process timeliness improves through use of automation and web portal distribution of information. Timeliness exceeds legal requirements.
- LEVEL 3Timeliness improves via state and federal collaboration, use of information sharing, standards, and regional information exchange hubs. SMA releases alerts and information immediately. Timeliness exceeds Level 2.
- LEVEL 4Information is available in near real time. Processes that use clinical information result in immediate action, response, and results. SMA has regional interoperability, which further improves timeliness over Level 3.
- LEVEL 5Information is available in real time. Processes improve further through connectivity with other States and with federal agencies. Most processes execute at the point of service. Results are almost immediate.
Business Capability Quality: Data Access and Accuracy
How accurate is the information in the process?
- LEVEL 1Use of direct data entry for information collection is manually intensive and susceptible to inconsistent or incorrect information. Stakeholders are unable to rely on information for decision-making.
- LEVEL 2HIPAA standard transactions improve accuracy of information but the decision-making process may be erroneous or misleading. Accuracy is higher than at Level 1.
- LEVEL 3Automation of information collection increases the reliability of SMA’s internal information. External sources of information use MITA Framework and industry standards for information exchange. Decision-making is automatic using standardized business rules definitions. Accuracy is 95% or higher.
- LEVEL 4Automation of information collection increases the reliability of SMA’s internal and external sources of information. SMA adopts MITA Framework and industry standards for information exchange by regional agencies. Decision-making is automatic using regional standardized business rules definitions. Accuracy is 95% or higher.
- LEVEL 5SMA adopts MITA Framework and industry standards for information exchange with national agencies. Decision-making is automatic using national standardized business rules definitions. Accuracy is 95% or higher.
How accessible is the information in the process?
- LEVEL 1SMA stores information in disparate systems including paper storage and obtains information manually.
- LEVEL 2SMA stores information in disparate systems, but automation and nationally recognized standards increase accessibility over Level 1
- LEVEL 3SMA obtains information easily and exchanges with intrastate agencies and entities based on MITA Framework and industry standards. Accessibility is greater than Level 2.
- LEVEL 4SMA obtains information easily and exchanges with regional agencies and entities. Accessibility is greater than Level 3.
- LEVEL 5SMA obtains information easily and exchanges with national agencies and entities. Accessibility is greater than Level 4.
Business Capability Quality: Cost Effectiveness
What is the cost of the process compared to the benefits of its results?
- LEVEL 1High relative cost due to low number of automatic, standardized tasks.
- LEVEL 2Automation improves process and allows focus on exception resolution, improving cost effectiveness ratio over Level 1.
- LEVEL 3SMA adopts MITA Framework, industry standards, and other nationally recognized standards further improving cost effectiveness ratio over Level 2.
- LEVEL 4SMA adopts MITA Framework, industry standards, and other nationally recognized standards for regional information exchange improving cost effectiveness ratio over Level 3.
- LEVEL 5SMA adopts MITA Framework, industry standards, and other nationally recognized standards for national (and international) information exchange. SMA increases cost effectiveness ratio over level 4.
Business Capability Quality: Effort to Perform; Efficiency
How efficient is the process.
- LEVEL 1Process is labor intensive. There is wasted effort or expense to accomplish tasks. Process meets minimum state process guidelines and SMA performance standards. Efficiency is low.
- LEVEL 2Automation and state standards increase productivity. Efficiency is higher than Level 1.
- LEVEL 3SMA adopts MITA Framework, industry standards and information exchange with intrastate agencies and entities improving efficiency to 95% or higher.
- LEVEL 4SMA adopts MITA Framework, industry standards and information exchange with regional agencies and entities improving efficiency to 98% or higher.
- LEVEL 5SMA adopts MITA Framework, industry standards and information exchange with national agencies and entities improving efficiency to 98% or higher.
Business Capability Quality: Accuracy of Process Results
How accurate are the results of the process?
- LEVEL 1Manual processes result in greater opportunity for human error. Accuracy is low. SMA launches outreach to a general audience but does not align content with target audience negatively affecting accuracy.
- LEVEL 2Automation and standardized business rules definitions reduce errors. Capability to match outreach with target audience improves the accuracy of the process. SMA improves accuracy above Level 1.
- LEVEL 3SMA adopts MITA Framework, industry standards and information exchange with intrastate agencies and entities. SMA uses methods to target outreach to contractors that met specific needs. Accuracy is 90% or higher.
- LEVEL 4SMA adopts MITA Framework, industry standards and information exchange with regional agencies and entities improving accuracy to 98% or higher.
- LEVEL 5SMA adopts MITA Framework, industry standards and information exchange with national agencies and entities improving accuracy to 98% or higher.
Business Capability Quality: Utility or Value to Stakeholders
How satisfied are the stakeholders?
- LEVEL 1Stakeholders lack confidence in information negatively affecting stakeholder satisfaction with the process.
- LEVEL 2Automation and standardization provides clear and useful information. Stakeholder satisfaction is greater than Level 1.
- LEVEL 3SMA adopts MITA Framework, industry standards and information exchange with intrastate agencies and entities improving stakeholder satisfaction to 90% or higher. SMA uses survey or questionnaire for information collection.
- LEVEL 4SMA adopts MITA Framework, industry standards and information exchange with regional agencies and entities improving stakeholder satisfaction to 95% or higher.
- LEVEL 5SMA adopts MITA Framework, industry standards and information exchange with national agencies and entities improving stakeholder satisfaction to 98% or higher.
Source: CMS MITA 3.0 Business Capability Model, Provider Management.pdf, pages 29-36.