Healthcare Reform Preppers
Exclusively for:
AAHAM
June 19, 2013
• The Status of Reform
• Understanding Today’s Enrollment Dilemma
• The Preppers Enrollment Survival Kit
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© 2012 Advanced Patient Advocacy
Today’s Outline
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•
Uncompensated care & bad debt increasing
•
Unmotivated patients who only seek enrollment when acute care
is needed
•
Patients who struggle with the complex processes and bureaucracy
•
Patients who fail to maintain enrollment (churning)
•
Reimbursement challenges
•
Understanding resources & getting patients connected
•
States limiting/reducing dedicated resources
•
Audits & take backs
© 2012 Advanced Patient Advocacy
Providers are Challenged
Why did we need reform?
A changing population with changing healthcare needs
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Congressional Goals with the new
Healthcare Law
For a more detailed version of this chart outlining major ACA provisions, see APHA’s
“Affordable Care Act Overview,” available at
http://www.apha.org/advocacy/Health+Reform/ACAbasics/.
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PPACA
Medicaid / Insurance Reform
Medicaid Expansion
Insurance Exchanges
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Insurance Reform
Carriers MAY NOT:
Carriers MUST:
•
•
Cover “essential health benefits”
•
Cover preventive services with no
co-pays or deductibles
•
Cover young adults on their
parents’ plan through age 26
•
Spend more on services, less on
profits (MLR)
•
Justify double-digit rate increases
(rate review)
•
Deny or limit coverage for
pre-existing conditions
Rescind coverage over simple
paperwork mistakes
•
Set lifetime caps on essential
coverage
•
Charge women more than
men (gender rating)
More information: Healthcare.gov: Rights and Protections
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(from the Affordable Care Act of 2010)
Medicaid Reform
• Simplify eligibility rules
and reduce confusion
• Streamline enrollment
and eliminate barriers
• Minimize lapses in
coverage (churning)
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Medicaid Expansion
• More people are
covered
• Expand Federal
Match (FMAP) to
help states finance
coverage expansion.
© 2012 Advanced Patient Advocacy
Medicaid Key Elements
Medicaid Expansion
Categorical
group
U.S. minimum
threshold preACA, 2009*
Children 0-5
133% FPL
Children 6-19
100% FPL
State
thresholds,
2009: medians ,
(ranges)
235% FPL
(133-300% FPL)
235% FPL
(100-300% FPL)
185% FPL
Pregnant
women
133% FPL
Working
parents
State's July
1996 AFDC
eligibility level^
64% FPL
Non-working
parents
State's July
1996 AFDC
eligibility level^
38% FPL
Childless
adults
Eligibility not
mandated.
State must
apply for waiver
to cover this
0% FPL
(0% FPL in 46
states; 100160% FPL in 5
states)
Elderly, blind,
disabled
Receipt of SSI^
(133-300% FPL)
(17-200% FPL)
(11-200% FPL)
75% FPL
(65-133% FPL)
Sources: Kaiser Family Foundation
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U.S. minimum
thresholds
under ACA,
2014**
133% FPL
133% FPL
(note traditional
vs new)
133% FPL
133% FPL
(note traditional
vs new)
A new eligible group: all adults not already eligible.
The ACA expands the minimum income eligibility threshold to
133 percent FPL (effectively 138 percent FPL) for everyone
except the elderly and disabled. This is a floor, not a ceiling: if
states already had higher thresholds for certain populations, or
want to set higher thresholds, that's fine.
Under the ACA expansion, the categorical definitions shown in
the table to the right will be less relevant than the difference
between "traditionally eligible" and "newly eligible" persons.
•
Those in any population who were already eligible in their
state (whether or not they were already enrolled) can be
thought of as "traditionally eligible." They will continue to
receive the services to which they are already entitled,
and states will continue to receive their standard federal
contribution for covering them, whether they enroll before
or after 2014.
•
Those in any population who were not previously eligible
but become eligible under ACA (which will include
nearly all childless adults, plus many parents a
nd some children depending on states'
current thresholds) can be thought of
as "newly eligible."
133% FPL
(note traditional
vs new)
133% FPL
(note traditional
vs new)
Receipt of SSI
Premium and Cost Sharing Limits for Individuals up
to 400% of Poverty Under Health Reform
Income (% FPL)
Coverage
Premium & Cost Sharing
< 138% FPL
Medicaid
 No Premium
 Cost sharing limited to nominal amounts for most services
139% - 250% FPL
Exchange
 Sliding scale tax credits limit premium costs to 3 – 8.05% of income
 Sliding scale cost-sharing credits
251% - 400% FPL
Exchange
 Sliding scale tax credits limit premium costs to 8.05 - 9.5% of income
 No Cost sharing credits
Notes: Exchange coverage and tax credits are limited to lawfully residing individuals who do not
have access to employer‐sponsored insurance. Lawfully residing individuals who are barred
from enrolling in Medicaid during their first five years in the U.S. may receive Exchange
coverage and tax credits. Premium credits will adjust annually.
Source: “Summary of New Health Reform Law”, Focus on Health Reform, the Kaiser Family
Foundation, June 18, 2010.
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© 2012 Advanced Patient Advocacy
Filing the Gap with the Insurance Exchange
ACA predicted to cut uninsured rate
Source: KFF: The Uninsured: A Primer (2012);
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Red =
not expanding
Sources: KFF: The Uninsured: A Primer (2012); Advisory Board Company: Where the States Stand
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What a mess can somebody help me?
• Yes, No and maybe
• Navigator and In Person Assistance Programs (IPAs)
– In Person Assisters – guide/direct/facilitate a connection to the
navigator or broker
– Navigators – focus on the physical mechanics of enrolling
– SHOP Navigators – focus on group market and act more as a
broker
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Who has the most to lose if consumers are not enrolled in the
healthcare coverage that best meets their needs?
• Federal Government
• State Government
• Insurance Carriers
• Providers
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© 2012 Advanced Patient Advocacy
Here is the Dilemma
How Can Providers Prepare?
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© 2012 Advanced Patient Advocacy
Tools Providers Need in Their Survival Kit
Understand your State’s decisions
• And the position of other States
Charity policy updates
• How will exchanges affect current charity write-offs?
• Adjust policies to be in line with NEW Medicaid guidelines.
What changes are needed in the registration process?
• New verification procedures (New Technologies)
• Are you asking THE RIGHT questions?
• Assistance strategies for those uninsured or
with life changes?
© 2012 Advanced Patient Advocacy
Update Policies & Procedures
Registration tools
The Registration team is the
front line, do they have the
tools they need to correctly
classify/route patients?
Be careful not to over rely on
technology solutions?
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Getting It Right The First Time
•
A 64 year old male patient
arrives in your Emergency
Department after an accident.
•
What primary I-plan do you
select at discharge?
– Common Answers: Self-pay, Commercial, MVA or Medicare
•
How does that selection affect the way the account tracks in your
system and future business office actions?
•
What questions do you need to ask to ensure this
patient is categorized correctly?
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Building an Enrollment Strategy
• Target
• Broaden
• Maximize
• Take advantage
of the Disability Opportunity
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• Avoid the collection agency approach
• Use technology to create efficiencies not short cut
the screening process
• All claims are not created equal
• Use automation to identify opportunity
• Stratify work segments to improve efficiency
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© 2012 Advanced Patient Advocacy
Segment & Target Population(s)
Do you know the categorical breakdown of your patient population?
•
Once you understand your patient mix then you can target the populations most likely to
qualify for assistance programs
•
Focus resources and customize the enrollment strategy
•
Develop an outpatient strategy that delivers enrollment assistance at the time and place
eligible patients access services
Categorical Patient Mix
Inpatient
Outpatient/ED
© 2012 Advanced Patient Advocacy
Not All Uninsured Patients are Created Equal
ED Case Study
This facility previously worked with an ED screening & enrollment process that
focused on post-discharge contact. A 12 month evaluation period was established
to man the ED from 10 am – 10 pm and they experienced the follow:
Results
•
56% increase in the number of Medicaid approvals
•
Increase converted charges by $1.1 m annually
•
At a reimbursement rate of 16%, approximately $176,000 cash annually
•
Increased staffing by adding 2 FTEs and other cost of $125,000
•
Return visit rate of 4 times annually on average (future charges of
$4.4 m covered) with annual reimbursement estimated at $500,000
© 2012 Advanced Patient Advocacy
Point-of-Service Modeling
STRATEGY: Initial contact during inpatient visit or at the time of care is not
enough, a strong follow-up program is essential.
•
Over-reliance on the patients word and diligence (no contact with patients attorney, etc.)
•
Set standard abbreviations and ensure all team members consistently document activity
•
Establish a post discharge follow-up program that includes outreach and ensures
filing deadlines are met
•
Eligibility verification process that is consistent and strategic
Recommend using an account management process, software or tool. This would ensure patients are not
falling into gaps, increase conversions and help with performance measurement .
© 2012 Advanced Patient Advocacy
How far will you go?
A broad enrollment solution will reduce your level of uncompensated Care
An effective enrollment program must be more than just Medicaid!
•
Social Security Disability Insurance
•
Veterans Benefits
•
Supplemental Security Income
•
Indian Health
•
COBRA
•
SCHIP
•
Pre-existing condition coverage
•
Immigrant programs
•
New Minor & Adult groups for Medicaid
•
Liability (MVA & WC)
•
Insurance Exchange Opportunities
Payments resulting from
enrollment by Payer
NonMedicaid
23%
Total Charges
Resolved by Payer
Disability
20%
Medicaid
77%
NonMedicaid
30%
Medicaid
50%
© 2012 Advanced Patient Advocacy
Are You Getting the Maximum Return on Your
Enrollment Solution Investment?
Expand Screening and Enrollment
•
More than just Medicaid
•
SSI is not enough
•
Extended benefit opportunities
(COBRA, ERRP)
64 Fed. Reg. 5160, 5170
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•
Pre-existing and high-risk coverage
•
Liability and Workers Compensation
© 2012 Advanced Patient Advocacy
Connect to the right Payer
Case Study:
Maximized Reimbursement
Originally classified as Medicare:
•
Six-year-old girl falls on
grandmother’s property
•
Ambulance visit to local ED
•
Injuries comprised of joint pain
(shoulder, hip, lower extremities);
contusions
$ 624.00 - Professional Charges
$ 2,847.95 - Institutional Charges
$ 3,471.95 - Total Charges
$ 2,151.01 - Adjustment
$
$
$
616.97 - Medicare Payment
76.97 - Other Payment
693.94 - Total Payments
20%
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Percentage Paid
Case reclassified as liability:
•
Interview with grandmother showed
active claim opened with her
homeowner’s policy
•
APA negotiated with adjuster
•
$5k available MedPay provision
•
APA advised refund Medicaid
$ 624.00 - Professional Charges
$ 2,847.95 - Institutional Charges
$ 3,471.95 - Total Charges
$
$
(616.97) - Medicare Refund
(76.97) - Other Refund
$ 3,471.95 - Liability Payment
100%
Percentage Paid
Go Broader
Strategy: Assist patient’s with programs outside of traditional Medicaid.
• Leverage existing programs like SCHIP
• Higher reimbursement opportunities and better coverage programs like
PCIP, COBRA, Disability, Crime Victims, MVA, etc.
The math behind expanding your enrollment program in the ED or other
outpatient points of access?
• Staffing cost
• Low reimbursement rates
• Future utilization rates (three to five times ED use per year)
Go Deeper
What enrollment opportunities exist for this patient?
Scenerio:
• Patient is 57 years old
• Entered the ED for the flu
• Presented with Anthem Blue Cross
• Currently not working due to side effects of dialysis
Strategy:
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•
Use trending
•
Data scrubs
•
Registration Staff Training
The Disabled Patient Gap
•
In a recent APA study we found that of the
patients admitted to the hospital with a medical
condition that would qualify as disabled under
SSDI/SSI 80% presented with commercial
insurance
•
Six months later, only 20% of that patient group
had claims that were paid by commercial
insurance and more than 63% were classified as
bad debt, self pay or charity as a final disposition
What do we know about
disabled patients?
•
They are frequent utilizers of healthcare
service
•
When they use services their services
are usually high balance services
•
They frequently max out benefits for
private insurance coverage
•
Less than 3 out of every 10 people who
apply for Social Security are approved
•
65% of Social Security approved
disabled patients are dual eligible
Disabled Patient Utilization
© 2012 Advanced Patient Advocacy
One out of every ten (12.6%)
working age Americans(ages
21-64) has a DISABILITY
SSA Case Study
This study measured the impact Bon Secours Health System in Richmond, VA
experienced as a result of a focused disability program and the use of electronic
medical records transfer directly to SSA for disability determination.
Results
•
42% improvement in the processing time of disability applications
•
$2.1 million in additional revenue recovered that was previously classified as
uncompensated care
* as reported in “Using the Nationwide Health Information Network to Deliver Value to
Disability Claimants: A Case Study of Social Security Administration and MedVirginia
Use of MEGAHIT for Disability Determination.”
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© 2012 Advanced Patient Advocacy
Impact of Focused Disability
Enrollment a Program
Strategy: Focus on disabling diagnosis and consider patients entire
situation. Do not rely on the patient to achieve success.
•
Be proactive
– Patients are high utilizers of hospital
services
– Compassionate allowance cases
– Data scrubbing and trending
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Accelerate disability process
•
Maximize Disproportionate Share reimbursement
© 2012 Advanced Patient Advocacy
The Disability Opportunity
Streamline
•
Processes (eliminate redundancies)
– Within in your enrollment process
– Between the facility and the state/county
– With the patient and your process
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Communication
– make sure everyone who needs to know has access to the information
– Create system-wide communication strategies
•
Partnerships (look beyond the hospital walls)
– leverage the resources others in the community have available
for patients
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It’s Decision Time
What role will your hospital play?
(officially or unofficially)
In an article published by Kaiser Family in October 2010 they state:
“In addition to the(se) systems safeguards, as well as essential due process protections,
states should maintain community-based enrollment assistance as an integral piece of
the enrollment system. Consumer and community organizations
and providers
can be partners in helping to identify and address enrollment problems
and facilitate enrollment and renewal for individuals unable to manage
self-service options.”
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What are my choices?
1.
Let the State & Federal
Governments handle enrollment
2.
Continue to provide enrollment
assistance at my current level of
involvement
3.
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Become the patients resource for all enrollment avenues
© 2012 Advanced Patient Advocacy
Choosing the Provider Role
Choosing the Provider Role
Educate, Navigate & Connect
• Providers will find themselves in a unique position
• Consumer/Patients will struggle to understand options
• Insurance exchanges will provide new guidance
Educated consumers connected to insurance programs that best meet their
financial and healthcare needs will yield the greatest reimbursement to
providers.
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Funding Opportunities
Watch for Funding
Opportunities & Apply
• Grants.gov
• HHS Grants Forecast
Community Transformation Grants
Investments in (and dissemination of) evidence-based and practice-based
community strategies and programs
Focusing on Priorities for Healthier Living:
• tobacco-free lifestyles
• active living and healthy eating
• high-impact quality clinical and other
preventive services
• creation of healthy and safe physical
environments
Run by CDC, funded by Prevention Fund
• $145M in FY 2011, $226M in FY 2012
More information: http://www.cdc.gov/communitytransformation/
• What extremes the political parties
will go to make a statement?
• The timing and outcome of legal
challenges?
• What will be the impact on
commercial and employer based insurance coverage?
• Where the funds to pay for the program will really come from?
• How all the details will come together: Exchanges, ACOs, Individual
Mandate, and the impact on both small and large businesses?
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© 2012 Advanced Patient Advocacy
Still So Much We Don’t Know
Segment
• Customized enrollment programs for different patient groups
• Use technology to expand opportunities not limit them
Partner & Expand
• Build relationships in the community that can increase the number of
insured patients
• Take a broad approach beyond traditional Medicaid & SSI
• Expand communication and share information system wide.
Educate, Navigate & Connect
• Ensure your patients are knowledgeable about their options
• Mitigate financial risk by connecting patients to programs with better
reimbursement
• Become the resource for coverage information
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© 2012 Advanced Patient Advocacy
The Moral of the Story!
Thank You
Michael D. Wilmoth, Esq.
mwilmoth@apallc.com
(703) 403-3521
www.aparesults.com
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Important Sources
J. Angeles, Explaining Health Reform: The New Rules for Determining Income Under Medicaid
in 2014, The Henry J. Kaiser Family Foundation, Kaiser Commission on Medicaid and the Uninsured,
06-02-2011, http://kff.org/healthreform/8194.cfm
P.. F. Short, K. Swartz, N. Uberoi et al., Realizing Health Reform’s Potential: Maintaining
Coverage, Affordability, and Shared Responsibility When Income and Employment Change, The
Commonwealth Fund, May 2011,
http://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2011/May/1503_Short_m
aintaining_coverage_affordability_reform_brief.pdf
S. Dorn, Implementing National Health Reform: A Five-Part Strategy for Reaching the Eligible
Uninsured, Robert Wood Johnson Foundation, Urban Institute, May 2011,
http://www.rwjf.org/files/research/72371urban201105.pdf
S. Dorn, The Basic Health Program Option under Federal Health Reform: Issues for Consumers
and States, Robert Wood Johnson Foundation, State Coverage Initiatives, May 2011,
http://www.statecoverage.org/node/2918
Medicaid Program; Eligibility Changes under the Affordable Care Act of 2010, 42 CFR Parts 431,
433, 435, and 457, [CMS-2349-P], RIN 0938-AQ62, Centers for Medicare and Medicaid Services
(CMS), HHS, August 12, 2011, http://www.ofr.gov/OFRUpload/OFRData/2011-20756_PI.pdf.
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More Important Resources
 apha.org/advocacy/reports
 Healthcare.gov (U.S. Dept. of Health and Human Services)
 State Refor(u)m (National Academy for State Health Policy)
 Health Reform Source (Kaiser Family Foundation)
Health reform summary; Implementation timeline; ACA federal funds tracker;
Statehealthfacts.org
 Health Reform Central (Families USA)
 Health Insurance 101 (Community Catalyst and Georgetown University)
 Enroll America
 Center for Medicare and Medicaid Innovation
 Federal Register: Health Care Reform
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