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The Genesis Information System The Genesis Information System (GIS) was designed to meet the data needs of an Orlando-based managed care plan, Genesis Health Systems. This plan, acquired by United HealthCare Plans of Florida, continues to use GIS in serving its approximate 75,000 Medicaid and commercial members. In addition, GIS has been installed in two other health care plans, Genesis Health Plan (New York) and Sunshine Health Plan (Ft. Lauderdale) in which it provides a full range of electronic data functions to their 16,000 and 1000 members respectively. GIS is a modularly-designed managed care data system. It is written in FoxPro and designed for operation on a PC-based network. Due to its FoxPro origin, the system seamlessly supports file export and import to Microsoft Word, Excel and Access. This permits the facile incorporation of features such as customized mail-merge letters, spreadsheet analysis and graphical representations. Currently all three installations use Novell Netware 3.12 as the network operating system, though the software can also be equally accommodated on a Windows NT-based network. The software supports mid-sized networks (1-150 users) in its present configuration and can be expanded to a much larger network size through adoption of a client-server format. Two of the three current installations are multi-site, demonstrating the portability of data across multiple offices. The existing modules are: Membership and Eligibility This module consists of multiple interlinked databases that record and track contractholder and member demographics, benefit types, selection and history of primary care physician(s) choice, and a trail of eligibility statuses. The module also contains many standard reports that produce membership data based upon various input criteria. The system also includes a powerful ad hoc querying capability that can be operated through either the native "Relational Query by Example" (RQBE), SQL or through a powerful commercial add-on, FoxFire. These three querying modalities, of course, can be used in conjunction with any of the modules herein described and to link data across modules. Membership Services This module contains several interlinked databases that record and track member queries and complaints. In addition, it can be used by internal plan administration to track membership or other action taken that pertains to a given contract or member. The module provides the capability of "bundling" all the membership service activity (or other action if so entered) for an easy on-screen or hard-copy single view of all activity for the designated member. It also data stamps the date, time and representative’s initials on each entry which are then sorted in most-current date/time order. The module includes both categorization of calls by type for statistical reporting and free-form notes as to the content of the call or action. Finally, the module allows electronic forwarding of call records to designated departments for follow-up and on-going status determination. The module also contains many standard reports that produce membership data based upon various input criteria. The system also includes a powerful ad hoc querying capability that can be operated through either the native "Relational Query by Example" (RQBE), SQL or through a powerful commercial add-on, FoxFire. These three querying modalities, of course, can be used in conjunction with any of the modules herein described and to link data across modules. Provider This module contains several interlinked databases that record and track provider-specific and office-specific demographics, payment modes and fee schedules, and credentialing information. The system allows non-interdependent grouping of providers at several levels (selection of PCPs, capitation, risk pools, payment of check, etc.). The module also contains many standard reports that produce provider data based upon various input criteria. These reports include routines for such diverse purposes as querying the National Practitioner Database or automatically creating a Provider Directory sorted by region and/or specialty. The system also includes a powerful ad hoc querying capability that can be operated through either the native "Relational Query by Example" (RQBE), SQL or through a powerful commercial add-on, FoxFire. These three querying modalities, of course, can be used in conjunction with any of the modules herein described and to link data across modules. Pre-Authorization This module contains multiple interlinked databases that record pre-authorization of both out-patient and in-patient services. The databases structure the parameters of pre-authorized services including such features as identification of scope of pre-authorized services (e.g. visits, type of referral care requested, authorized service dates, etc.), on-going eligibility verification and direct linkage to claims. The module also contains many standard reports that produce pre-authorization and quality assurance data based upon various input criteria. The system also includes a powerful ad hoc querying capability that can be operated through either the native "Relational Query by Example" (RQBE), SQL or through a powerful commercial add-on, FoxFire. These three querying modalities, of course, can be used in conjunction with any of the modules herein described and to link data across modules. Claims This module contains many interlinked databases that record and track payment of medical claims. The module records invoice data and verifies eligibility of receipt of services by member, provider, and procedure performed. In addition, the module performs numerous other edit checks including benefit type, service dates, pre-authorization prior to actual adjudication of the claim. The system maintains provider-specific and benefit type-specific fees (within a single provider). A provider may also elect to use multiple fee schedules for a single benefit type (primary and secondary defaults). The claims module also provides for multi-level adjudication of claims, the ability to approve, pend or deny individual components of claims, make retroactive adjustments to claims. In addition to payment in accordance with procedure-based fee schedules, the module supports payment by DRG (hospital or provider-specific) or by per diems. The module also contains many standard reports that produce claims data based upon various input criteria. The system also includes a powerful ad hoc querying capability that can be operated through either the native "Relational Query by Example" (RQBE), SQL or through a powerful commercial add-on, FoxFire. These three querying modalities, of course, can be used in conjunction with any of the modules herein described and to link data across modules. Capitation This module contains several interlinked databases that calculate and record monthly capitation payments for providers. Capitation amounts are provider-specific and can vary in accordance with benefit type, age and sex. The module also provides the capability of maintaining multiple risk pools which are also provider-specific and can vary in accordance with benefit type, age, sex and medical treatment type. The amounts accrued in the pool(s) are designed to be debited by corresponding medical claims payment data, variable or fixed miscellaneous other deductions or plan-defined re-insurance levels. The module also contains many standard reports that produce capitation and risk pool data based upon various input criteria. The system also includes a powerful ad hoc querying capability that can be operated through either the native "Relational Query by Example" (RQBE), SQL or through a powerful commercial add-on, FoxFire. These three querying modalities, of course, can be used in conjunction with any of the modules herein described and to link data across modules. Medical Encounters This module contains several interlinked databases that record and track physician and other provider medical encounters. Key data such as provider, service date, member, diagnosis, procedure(s) performed and fee-for-service equivalent values are stored or calculated. Due to its links to the other modules useful comparative utilization data can be developed. Together with data from the Claims and Rx Modules medical profiles of individual members can be created for immediate retrieval and use for utilization management or quality of care purposes. The module also contains many standard reports that produce medical encounter data based upon various input criteria. The system also includes a powerful ad hoc querying capability that can be operated through either the native "Relational Query by Example" (RQBE), SQL or through a powerful commercial add-on, FoxFire. These three querying modalities, of course, can be used in conjunction with any of the modules herein described and to link data across modules. Rx This module appends externally-generated Rx-utilization data onto an Rx database that is linked to the other system modules. This database is often linked to a DEA databases that allows the identification of prescribing physician whether or not that provider is affiliated with the plan. It also contains several Rx utilization reports which provide member-specific and PCP-panel-specific Rx utilization. In addition, therapeutic class comparative cost data is generated so as to guide providers or the plan in either formulary determination or dispensing alternatives. The system also includes a powerful ad hoc querying capability that can be operated through either the native "Relational Query by Example" (RQBE), SQL or through a powerful commercial add-on, FoxFire. These three querying modalities, of course, can be used in conjunction with any of the modules herein described and to link data across modules. |
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