UHCD Ideas

Request intake portal for the UnitedHealthcare Digital product team

National Provider Tiering - Rules Engine to support Tiered Providers Display

See Attached VFQ/SOD - UnitedHealthcare has an opportunity to improve affordability for constituents by implementing a national tiering strategy for E&I commercial business with tiering capabilities across all products, providers, and benefit categories. The majority of commercial business plans are considered “two tier” with in-network and out-of-network benefits. “Tiered plans” typically refer to three tiers of benefits with both tier 1 and tier 2 being in-network and having a defined benefit differential (currently set at up to 30% for coinsurance).

While three tier plans do exist today, there are limitations and the tier 1 benefits are typically contained to a relatively small group of providers and benefits. National tiering capabilities will enable us to move physicians, national labs, ancillary providers and hospitals within tiers nimbly and with minimal manual intervention or operational processes.

At a high level, national provider tiering functionality should include the following:

  • Business Segments: National Accounts, Key Accounts, Public Sector and Small Business
  • Platform: UNET (PRIME and ACIS)
  • Products: All, including but not limited to PCP-centric, NexusACO, Open Access, and Gated products
  • Client types: single-site and multi-site employers
  • Funding: ASO and FI, and policies under Minimum Premium arrangements
  • Sales Flexibility: Must allow for variation by plan or policy
  • Guest
  • Jul 31 2017
  • Planned
Priority Critical
Estimated Cost ($ Dollars) $12
Business Problem

The current configuration for tiered benefit plans using IPA/GSP functionality has multiple challenges, including:

  • Multiple IPAs are woven together to create a “national” GSP through the use of the TOPS reciprocity table. This creates business operations gaps:
    • Manual support of multiple IPA/GSPs creates heavy operational lift and opportunity for manual error
    • Providers that should be promoted to Tier 1 or demoted to Tier 2 are identified by UHN, then must be manually loaded into the GSP(s).
    • There is no current maintenance support process or staffing for TOPS reciprocity (TCI) table when provider changes are made.
    • The TCI table is limited to 800 lines, which is not sufficient for future growth of the ACO contracts.
    • Multiple TOPS TCI tables cannot be supported because there is only one place to put the table number on the policy. This is a conflict when multiple GSPs are needed (Tiering plus Diabetes Disease Mgmt, for example, both use GSPs)
    • Loading providers who practice across state lines is problematic with multiple IPAs.
  • Dual deductible plans have separate deductibles for applicable tiers (Tier 1, Tier 2, Tier 3) within the plan design and dual deductible plan designs cannot be supported today as market requires.
    • System cannot exclude specific benefit and/or service categories from the tiering structure. We cannot move certain services to always accumulate to a specific tier, which is needed.
    • Both MHSA and Rx claims need to be incorporated into the Tier 1 deductibles, which are not done today.
  • Hospital Tiering in the current NexusACO offering has been a challenge. In the current setup, members have to be placed in different plans due to our inability to tier hospitals as desired both inside and outside the NexusACO service areas.
Business Value
Business Risk

If this update is not made,

  • UHC’s ability to provide affordable tiered benefit plans to multi-site national clients will be hindered.
  • Multiple operational gaps and manual processes limit ability to meet market demand.
  • ACO contracting efforts will be hindered and market position will continue to trail behind competitors.
Date Required By 2018-05-31
Who would be willing to pay for it? yes
Regulatory No
Regulatory Date
Client Commitment Comments
  • Attach files
  • Admin
    August 10, 2017 14:32

    UHCD product managers will attend requirement kickoff meetings - Rally is reviewing high level solution in greater detail for feasibility

  • Admin
    August 24, 2017 13:36

    1. Has funding officially been secured?

    2. What is projected timeline for deployment?

  • Guest commented
    August 24, 2017 13:42

    1. Funding has been secured.

    2. Deployment “requested” timeframe is Q2-2018. This is still being negotiated.

    Gabriela M. Rapp, IT Program/Project Manager,
    CSM®, PMP®, SAFe Agilist®
    131 Morristown Road, Basking Ridge, NJ
    (office) 908.696.5915 | (alt) 732.442.3294 |
    (email) gabriela_rapp@optum.com

  • Admin
    October 31, 2017 20:59

    Per 10/31 Steering Group, Tom Bendson, Reed Bjergo to work with their project teams to decelerate engaged on NPT until Nexus, Critical Clients (Hospital/Onc), MPPS can be launched or worked through