Anthem Inc. Information Systems
Joanne Wood
DeVry University
HIT 120
Professor Dennis

Anthem Inc. Information Systems Anthem, Inc. is one of the biggest insurance carriers in the United States. It spans multiple states with multiple different names doing business as Anthem, Inc. Anthem, Inc. is based out of Virginia City, Virginia, however a large number of its staff members work from home utilizing electronic medical records for all of its healthcare information system. Anthem, Inc. serves all ages, from birth to elderly and offers different health programs for all their different members. Some of these programs include behavioral health program, disease management program, and complex case management. Anthem, Inc. is accredited by the NCQA, which is one of the top leading health care accreditation organization. Anthem, Inc. has many different clinical, financial, and business applications. The common ones include CareCompass, member 360, and Facets. Because Anthem, Inc. is medical based, the core program uses is CareCompass. This health information system it utilized by nurses, doctors, administrators, and the support team assisting members when they call in and need assistance. Our medical directors have access to CareCompass from any computer they use, making the interactions much more accurate and personal. Anthem, Inc. has its own personal pharmacy department which are able to see member information which allows the pharmacist to check interactions with medications that they may not know about. Utilization and pre-authorization departments have access to CareCompass, but in a limited fashion. The information that these team members receive is from the provider requesting authorization for a procedure. They utilize this information and compare to pre-determined criteria using Milliman guidelines. Anthem, Inc. does not provide therapy services personally, however there are therapists that run some programs and provide interactions with members. They have access to member information as well. Anthem, Inc. does not use any paper records any further. The entire company is electronic medical records, making it a great company to work from home for. Employees can work anywhere in the United States for any number of states that they may not live in. All users are set up through the information technology department. Every different position and discipline have different access based on their position and needs. This access is ordered by the manager for specific access. CareCompass is focused on providing an innovative, interdisciplinary workflow solution that can be used to guide the collaborative care team in the organization. The system is used for many areas within the insurance arena. This includes, pre-authorization, disease management, case management, eligibility verification, and limited medical records. This system provides the needed information to perform the highest quality of care not received directly from the members. CareCompass does not talk with other programs within Anthem, Inc, but allows authorized personnel to document conversations and assessments that take place with the members. CareCompass is easy to learn and is straight forward. There are certain forms and pages for specific information. Each progress note has a named topic that allows for reports to be run accurately. This information gives statistics on each individual associate or as a whole company. The downfall to this is that if the name of the progress note is typed incorrectly in any manner, the information will not pull into the reporting data, making the data inaccurate. There are usually updates to this system about two times a year, which I am told, causes many difficulties for the employees using the system. It takes a couple weeks for all the wrinkles to be ironed out, but I am told that the updates are almost always positive and makes the workflow easier for the associates.
Another program used by Anthem, Inc. is member 360. This program is used to verify identity, address’s, doctors, medications, and authorizations for each individual member. It provides information including when the last medications were filled and to which pharmacy, when the last doctor appointments were and which doctor, occasionally labs results are listed, however I am told this is rare as the labs do not report the results to the insurance company. The member 360 is a wealth of information regarding the member’s past care, billing, facilities, and emergent care. The case managers use this very frequently, making it easier to provide answer to members as well as information to question the member about. One of the down sides of this program is that it is only updated every 30 days, so some of the information needed to provide guidance to the members is not present at the time of the call. This makes it difficult to provide information about authorizations or if a request was requested yet. Although this causes difficulty at times with members, there are other ways to find this information within other systems. This system interacts with the member information tab within CareCompass, although when information is changed within the CareCompass demographic area, member 360 does not update immediately, as the information within CareCompass does. This allows the associate to be able to verify information in two different areas.
The third system I would like to talk about is Facets. This system provides guidance for the associates providing medical advice to members over the phone. The Facets Workflow application includes advanced client service features that improve your ability to research and track inquiries from members, providers, groups, subgroups and non-members. Associates can access a wide range of information—from claims, to billing, to provider UM—all from client service screens. As a result, they can answer questions efficiently and accurately on the first call, improving the rates for first-call resolution and helping to reduce costs and improve client satisfaction. The system includes best practice guidelines for specific diagnoses, information about what is covered for members as well as where the member may be able to find specific services. The downside to this system is it doesn’t always have the information that is needed and the associate is forced to use the internet for some information and guidance.
During my research I learned how many different systems are used to provide assistance and medical guidance to its members. If the associate is not able to find an answer in one system, there is usually another way to find the answer. If not, the associate uses the internet to provide information, teaching, and guidance to Anthem, Inc.’s members. I found it interesting to learn how each individual employee was given access to certain areas of the systems. An associate working in case management was not typically given access to the criteria that is needs to be met for a procedure to be approved, but is given access to the personal medical information. A case manager is able to see what the final decisions are as far as requests for procedures, but are not able to see the criteria to make that decision.
Overall, Anthem, Inc. appears to be very organized and every associate seems to have the appropriate access needed to provide assistance and guidance to the members. The one issue I believe would benefit the company would be having the member 360 update every 24 hours as the CareCompass information does. This would provide more accurate information and save time for the associate attempting to help the member having to change systems to provide the information.

Reference List

Cerner. (2011). CareCompass. Retrieved April 17, 2016 from https://store.cerner.com/items/1482 Trizetto. (2016). Facets workflow. Retrieved April 17, 2016 from http://www.trizetto.com/PayerSolutions/CoreAdministration/Facets/Workflow/ Business Analyst Training Online. (n.d.). What is facets? Retrieved April 17, 2016 from
http://www.businessanalysttrainingonline.com/index.php/interview-questions/explore-facets/242-what-is-facets.html