Medicare Advantage (MA)  Operations Division – Facets System Implementation

Copyright 2013  Advanta Healthcare Partners

The leadership group of a national Medicare Advantage (MA) Operations Division needed to migrate the claims processing of their Health Maintenance Organization (HMO) product from the EZ-CAP system to the TriZetto Facets system.  This migration would allow the executives to achieve an enterprise goal of establishing a common information systems platform for all of its products in the Medicare eligible population.  

Previously, the health plan had selected the TriZetto hosted Facets product as the core claims processing system. The Facets application was already supporting the plan's preferred provider organization (PPO) and private fee for service (PFFS) products. The EZ-CAP system was creating challenges for the MA plan to profitably grow their HMO membership, and having two different systems was costly and reduced staff productivity.

The operations leadership of the health plan required industry and business expertise from Advanta to assist the business team and end users while collaborating with the health plan's Information Technology (IT) Department to implement Facets within the HMO product line.  The organization did not have experience migrating an HMO product to a new system and relied on Advanta’s past experience with this situation and our working knowledge of the Facets system.

Advanta provided project management, Facets system implementation and claims expertise to the implementation effort.  The team provided guidance and support from the inception of the project to the ‘go live’ of the Facets system, as well as post deployment activities.  The implementation was successful and completed on time.  As a result of migrating the HMO product to the Facets system, the MA Operations Division achieved a $3.5 million savings.         


The Client’s Challenges

The primary challenges facing the team:

• The EZ-CAP system was unable to support the client’s membership and product growth plans and was limiting the client’s ability to quickly respond to changes in the market place.  

• The HMO product line is the most challenging product for a migration as it has more rules, criteria, and decision points than the PPO and PFFS product lines.  

• There was a shortage of internal subject matter experts with experience in the migration of an HMO product to a new system.

• To simplify operations and information systems staff productivity, the MA plan no longer wanted to have their product portfolio supported by multiple claims processing systems.  Moving to a common platform would not only increase staff productivity, but also reduce operating costs and add new functionality to the HMO product’s processing capability.


The Advanta Solution

Advanta staffed the project team that partnered with the business side and collaborated with the enterprise’s IT Department and TriZetto, the external system vendor.  Leading the Advanta team was a Project Management Institute (PMI) certified individual who had over 10 years of health insurance claims processing system implementation experience, specifically with the Facets system.  The team consisted of business analysts, testers, and trainers with a background in the Facets system and claims processing.  Advanta’s project manager developed the project work plan for the 18-month implementation period and subsequently managed to the plan.  Advanta supported the implementation throughout the lifecycle.

The scope of our work within the plan included membership accounting, enrollment, call center operations, claims, medical management, provider relations and management, and finance.  Advanta conducted interviews that involved the elicitation, prioritization and documentation of the business requirements for the new system.  Requirements were based upon interviews with key senior leaders and end users.  The requirements were identified by key business function and documented using a standard business requirements document (BRD) tool.  The team worked with the IT team to review and finalize the business requirements that would drive IT development and configuration efforts.  

The team reviewed the “as is” policies, procedures, and processes.  The business requirements represented the basis for identifying and defining the new policies, procedures, and processes.  Based on the new requirements, Advanta developed the “to be” policies and procedures, and recommended the new processes.  Additionally, Advanta developed desktop procedures and work aids to support the end users in the new operating environment.  

Advanta developed User Acceptance Testing (UAT) scenarios and utilized the use cases to provide feedback on IT’s development and configuration activities.  The team identified if the system was performing correctly and documented any errors.  They reviewed the issues with the IT team who then reconfigured the Facets system to meet the original business requirements.  

Advanta’s team was responsible for providing oversight and management of the training of end users.  Advanta developed the curriculum, the courses, and the prerequisites along with conducting the training on the Facets system functionalities and the new policies and procedures.  The training, which included both face-to-face and web-based venues, was coordinated and scheduled by the Advanta team.  Advanta continued to provide support after the Facets system was deployed.  During post deployment, Advanta provided guidance and expertise as issues and questions arose for the end users and worked with the business and IT teams to resolve them.  The team was instrumental in finding solutions to the problems and documented any changes to the policies and procedures.  


The Results

As a result of the team’s support and services, the MA Operations Division successfully achieved the migration of the HMO product from EZ-CAP to TriZetto Facets within the targeted 18-month implementation period.  The re-platforming to the Facets system created an opportunity to curb the increasing cost trends and generate administrative savings with the resultant decrease of $3.5 million.  

The addition of the HMO product to the Facets system resulted in more streamline business processes and a common platform for all three products.  The common platform enabled the IT Department to more easily install upgrades; provide ongoing support; and maintain the system.