Medicaid Management
Stacy Calvaruso, CHAM
Assistant Vice President – Patient
Management, Ochsner Health System
Congressional Budget Office……
Healthcare Reform is expected to
result in Medicaid volumes growing
from 39 Million to 55 Million
eligible individuals by 2014
Pro-Active Approaches to upcoming
Medicaid Changes
• The Patient Protection and Affordability Care Act
(PPACA)
• Medicaid Application Processing
• External Vendor
• Internal Processes
• Financial Counseling
• Patient Profiling
• Emergency Department Focus
• Metrics to measure success
• Denial Reports
• Subsequent Visits
Ochsner Health System
• SE Louisiana's largest non-profit, academic, multi-specialty,
healthcare delivery system
• Named Consumer Choice for Healthcare in New Orleans for
15 consecutive years
• Only Louisiana hospital recognized by U.S. News and World
Report as a "Best Hospital" across seven specialty
categories
• 8 hospitals
• 38 health centers in Louisiana
• 12,500 employees
• 850+ physicians in over 90 medical specialties
• 300 clinical research trials annually
Patient Protection and Affordable Care Act
(PPACA)
Commonly known as ‘Obamacare’
•Effective March 2010
• Specific provisions to be phased in thru 2020
•Effective April 2010
• Medicaid eligibility expanded to include all
individuals and families with incomes up to 133%
of the poverty level along with a simplified CHIP
enrollment process.
Patient Management and MEP Unit
Patient Management Division
• Hospital Patient Access Services
• Clinic Patient Access Services
• Pre-Service Center
• Pre-Registration
• Scheduling
• Financial Counseling
SWOT - Program Impact
• Healthcare Providers should take steps to increase
their understanding of how existing processes may
need to be altered in this environment.
• Develop multidisciplinary teams that are dedicated to revising key
procedures.
• As a part of overall Healthcare insurance reform
programs, there will be a renewed and aggressive
nature of reimbursement audits
• Close scrutiny of the referral and authorization process.
• Many facilities already struggle with this process and Ochsner was
no different.
Overall Objectives
• Reduced Authorization and Eligibility Denials
• Ensure consistent financial clearance
• Improved POS Collections
• Pre-service patient notification and education
• Improved Revenue –
• Fewer delays for Financial Clearance
• Decrease Bad Debt Volume – Proactive identification of
options and resources for the patient’s out of pocket
liability
•
•
•
•
•
100% screening for Medicaid eligibility
Charity care based on a sliding scale
Prompt pay discounts
Propensity to pay evaluation
No-interest payment plans
1 -Medicaid Application Process
2010 Results
Outside Vendor
• 6734 Applications
• No ED Coverage
• No Clinic Coverage
• Very limited on-site presence
Medicaid Application Center
• State Certification for Financial Counselors
to accept applications
• 8A – 19P E D coverage
• 1 year agreement with new vendor to teach
us how to expand our knowledge
• Deep Dive into demographics surrounding
each facility
• Extensive work-flow development
• Comprehensive training
Financial Counseling – Required!
•
•
•
•
•
Pre-Service Center
Emergency Department
Mobile to Bedside
Clinical Partner
Various Clinics
• Part of treatment team for high $
• Walk-in’s
• Open to the Public
Patient Profiling?
• Based on data elements
• Age, income, and zip code
• Considerations
• Estimated cost of care and patient out of pocket
• Propensity to Pay
• The likelihood of eligibility for financial assistance
• Financial clearance staff provide “financial informed
consent”
• patterned after standard pre-surgical informed consent
• seeks to educate each patient about coverage benefits
• Other options
• 0% Interest Payment Plans
• Charity Care, Financial Sponsors, Community Resources, etc.
Prepare for Medicaid Growth
Registration
• Eligibility Tool with 270/271 expanded information return
• 3rd Party Payor Options
•
•
•
•
Victim’s Compensation
Local Charities
Social Security / Disability
COBRA
• Profiling again… Query Medicaid
• Medicare primary
• Self Pay over 45 yrs old if unemployed
• Inform patients of Medicaid enrollment opportunities
• Prioritize screening and enrollment efforts based on expected clinical
outcomes / future needs
Eligibility Program Results
The results include approvals, founds coverage and
subsequent visits:
Approvals/Founds
•Number/Quantity - 15,246 approvals
•Gross Charges - $57.9 million
•Net Revenue - $13.3 million
Subsequent Visits
Number/Quantity - 19,961 visits
Gross Charges - $96.0 million
Net Revenue - $21.4 million
Program Results for FY 2011
Gross Charges - $153.9 million
Net Revenue - $34.7 million
(net expected reimbursement)
Program Cost - $7.5M (est)
2 - Medicaid Auth Task Force
Objectives
• Understand weaknesses in current process
• Prepare for increase in Medicaid administrative paperwork
• Improve communication and accountability
• Reduce Denials
• Reduce YAA’s
• Expand to areas with missing auth related items
Expected ROI on project
Year 1 Reduction of $9M of Gross Charges in denials
Year 1 Reduction of $2.37M in YAA
Savings to organization
Year 1 = $2.2M
Year 2 = $1.37M
Year 3 = $853K
Total = $4.46M
Estimation of 60% reduction in denials over 12 month period in year 1
based on Oct-Dec denials received.
Savings reduced by Database & FTE salaries for 2012.
September thru October 2011 Results
Medicaid Denials
Top10 Denial Reasons
Denial Code
CO-16
CO-38
CO-29
CO-31
CO-197
N29
CO-22
CO-119
CO-140
N54
Description
Claim missing/lacking info
Services not authorized/provided by designated provider
Timely filing
Patient not identified as insured (Name/# mis-match)
Pre-Cert / Authorization missing
Missing documentation / notes necessary to support claim
Coordination of Benefits
Benefit Max Reached
PCP Authorization Missing/Invalid
Claim / Authorization do not match
Total
Gross charges denial amount
Count
696
509
479
199
159
129
87
81
66
65
2,470
Denied Amount
$3,931,206
$566,137
$1,268,251
$1,446,232
$1,709,220
$225,612
$101,545
$55,607
$309,961
$936,165
$10,549,934
September - October 2011 Results
Medicaid Denials
Top10 Denial Reasons
Denial Code
CO-16
CO-38
CO-29
CO-31
CO-197
N29
CO-22
CO-119
CO-140
N54
Description
Count
Claim missing/lacking info
696
Services not authorized/provided by designated provider
509
CO-140 PCP Authorization
Timely filing
479
Missing/Invalid
Patient not identified as insured (Name/#
mis-match)
199
CO-197
Pre-Cert / Authorization
missing Pre-Cert Authorization
159
Missing
Missing documentation / notes necessary
to support claim
129
Coordination of Benefits
87
Benefit Max Reached
81
PCP Authorization Missing/Invalid
66
Claim / Authorization do not match
65
Total
2,470
Gross charges denial amount
Denied Amount
$3,931,206
$566,137
$1,268,251
$1,446,232
$1,709,220
$225,612
$101,545
$55,607
$309,961
$936,165
$10,549,934
First Step - Identify who does what
Pre-Service Center
•
•
•
•
Pre-Certs
Referrals
Authorizations
Benefit
Verification
• PreRegistration
• Financial
Clearance
Admit Department
• Initial Payor
Notification
• Initial PreCertification
• Benefit
Verification
• Payment
Arrangements
• Registration
• Referrals
Utilization Mgmnt
• Continued
Stay Reviews
• Initial
Clinicals
• Facilitates
Peer to Peer
• D/C
assistance
• Confirms
appropriate
status
Second Step – Identify root cause?
Lack of Automation, Communication, and Follow-thru
 Lack of Denial data specific to PM
areas
 Lack of automation
 Documentation in multiple places
 Inability to know who was
assigned to a patient
 Complex rules and requirements
 Rotating staff
 Leadership challenges
Not my job syndrome!
2nd Step - Remove the excuses!!
How should we resolve the issue?
• Use the data to determine what we are doing
wrong
• Denials
• Claim hold volume
• YAA’s
• Determine who should ‘own’ the process
• Admissions
• Utilization Management
• Fix the problem!
Denial Data Review
All Denials received October thru December 2011
( Regardless of Admit Date )
TOTAL NON-AUTH & ELIGIBILITY DENIALS
Denial Category
Eligibility
Non-Auth/ MCD Non-Covered
Non-Auth/ No PCP Referral
Non-Auth/ Precert
Grand Total
Count
Dollars
1,768
$5,611,989
88
$539,055
1,452
$1,384,250
605
$8,786,058
3,913
$16,321,352
Denial Data Review
Admit date prior to 10-1-11
Denials received in October – December 2011
Gross Denial Amount
TOTAL NON-AUTH & ELIGIBILITY DENIALS
Denial Category
Eligibility
Non-Auth/ MCD Non-Covered
Count
Dollars
1,197
$3,682,139
54
$423,483
Non-Auth/ No PCP Referral
976
$944,164
Non-Auth/ Precert
399
$5,605,116
Grand Total
2,626
$10,654,903
Team Resources
 Map out current flow
 Include key stake holders in improvement
discussion
 Identify failures without pointing fingers
 Identify needs on how to improve
Take Action!
Taking Action…..
Process 1
Process 2
Share denial data, hold
weekly meetings, remove
the excuses, identify key
stakeholders and share
accountability
Educate on payor
guidelines, understand how
to use system, identify tools
that work, develop tools to
meet needs
Process 3
Process 4
New reports, leadership
involvement, Access
database
Confirm that efforts match
results and maintain
accountability
October – December Denials
Gross denials and the resulting YAA posted for
DOS after October 1, 2011
NON-AUTH & ELIGIBILITY DENIALS
RESULTING IN A YAA
ADMIT DATE BEFORE/AFTER 10/1/11
TOTAL NON-AUTH & ELIGIBILITY DENIALS
ADMIT DATE BEFORE/AFTER 10/1/11
Denial Category
DOS After 10/01/11
Count
Dollars
Count
Dollars
Adj Amount
1,287
$5,666,449
38
$517,384
($36,915)
571
$1,929,850
21
$276,508
($737)
34
$115,572
3
$12,031
($49)
Non-Auth/ No PCP Referral
476
$440,086
3
$2,045
($4,397)
Non-Auth/ Precert
206
$3,180,942
11
$226,800
($31,732)
DOS Before 10/01/11
2,626
$10,654,903
252
$363,665
($269,859)
Eligibility
1,197
$3,682,139
102
$105,675
($14,859)
54
$423,483
4
$11,333
($291)
Non-Auth/ No PCP Referral
976
$944,164
126
$91,916
($220,807)
Non-Auth/ Precert
399
$5,605,116
20
$154,741
($33,902)
3,913
$16,321,352
290
$881,049
($306,774)
Eligibility
Non-Auth/ MCD Non-Covered
Non-Auth/ MCD Non-Covered
Grand Total
Metrics to be monitored
• Performance Measurement
• Ins Ver Secure Rate (Scheduled)
• Ins Ver Due Diligence Complete Rates (Non-Scheduled)
• PreReg Completion Percentage
• Ins Ver and PreReg Days Out
• Authorizations Obtained/Completed
• Financial Counseling Sessions Completed
• 100% Inpatient
• 90% Emergency Department
• 80% Outpatients with Bad Debt and/or High Risk Score
• B/D and Charity Care Adjustments
• Claim Edits, Rejections, and Denials
• Yield Affecting Adjustments
Lessons Learned
Leveraging technology is crucial to achieving high performance
standards in a volume-driven environment and the increase of
Medicaid patients will impact those who are not ready.
The lack of collaboration across service teams will negatively affect
organizations resulting in the following:
•Loss of Revenue due to denials that result in Yield Affecting Adjustments
•Lack of automation to fully assist with cross-department work flow
•Poor communication between the various department
•Inefficiencies that result in rework across the revenue cycle
Questions?