Under the terms of the agreement, announced Tuesday, HP will process approximately 12 million Medicaid claims for approximately 300,000 Nevada residents per year, aid the state in detecting potential Medicaid fraud or abuse, and add new decision-support systems and services.
HP spokesman Bill Ritz told InformationWeek that HP will implement Thomson Reuters' J-SURS data analytic tool, a nationally recognized, Centers for Medicare & Medicaid Services (CMS)-certified surveillance and utilization review subsystem that doubles as a fraud and abuse detection application.
"J-SURS is a data mining/report-generating system that uses health claims and encounter data to produce comprehensive profiles of service utilization by healthcare providers, as well as profiles of services received by health system recipients," Ritz said. "As a compliance tool, it also aids in detecting, investigating, and prosecuting potential waste, fraud, and abuse by providers and beneficiaries."
Ritz also said HP will upgrade Nevada's current decision support system (DSS) to the newest release of Thomson Reuters' Advantage Suite DSS product. Thomson Reuters' Advantage Suite integrates information from diverse sources and systems and organizes the data to support decision making.
The customized application will help users access and manage data for the management administrative reporting subsystem (MARS) and surveillance and utilization review subsystem (SURS), as well as advanced healthcare decision support applications, including population health management and performance measurement.
"The DSS will primarily focus on healthcare costs, utilization, and quality measures to aid the state in making improved policy decisions and measuring better healthcare outcomes," Ritz said. "Users accessing the DSS will benefit from having enhanced data elements such as clinical aggregates for inpatient admissions and episodes of care, specialized application constructs for continuous enrollment, and metadata for clinical measures."
The contract also calls for HP to process medical and pharmacy claims, review and process prior authorization requests, and administer utilization management and personal care reviews for the state. HP also will assist Nevada's Medicaid program in connecting healthcare providers with critical health information to improve overall care.
"We look to HP for a smooth transition to more effectively administer benefits to our residents and provide excellent policy guidance to help us prepare for and manage challenges such as healthcare reform," Charles Duarte, Nevada's Medicaid administrator, said in a statement. "We selected HP based on its deep knowledge and experience to help us enhance our Medicaid program operations to benefit Nevada's Medicaid clients, healthcare providers, and other stakeholders."
HP administers $95 billion in benefits a year and serves as fiscal agent or principal IT provider to 21 other Medicaid programs.
The Nevada Division of Health Care Financing and Policy provides medical benefits through Medicaid and the Children's Health Insurance Program (CHIP), called Nevada Check Up. These programs spend $1.5 billion annually on more than 300,000 low-income Nevadans, including families, children, the elderly, and people with disabilities.