Maximizing Revenue and Minimizing Cost
Training Sponsored by
Tribal Self-Governance Advisory Committee
Arlington, VA
Myra M. Munson, J.D., M.S.W.
Sonosky, Chambers, Sachse, Miller & Munson LLP
May 7, 2014
myra@sonoskyjuneau.com
Sonosky, Chambers, Sachse, Miller & Munson, LLP
302 Gold Street, Suite 201, Juneau, AK 99801
907-586-5880
Maximizing Revenue and Minimizing Cost
Webinar Presentation Sponsored by
Tribal Self-Governance Advisory Committee
Arlington, VA
myra@sonoskyjuneau.com
Washington, DC
Myra M. Munson, J.D., M.S.W.
May 7, 2014
Juneau, AK
Anchorage, AK
Albuquerque, NM
San Diego, CA
Where to Start – Consider Roles
Tribes juggle many roles:
• Tribal government
• Health provider
• Employer
OBJECTIVE: To maximize revenue and minimize costs
associated with health care, while achieving
governmental objectives of improving the physical,
spiritual, and economic well-being of members and
community.
Sonosky, Chambers, Sachse, Miller & Munson, LLP
302 Gold Street, Suite 201, Juneau, AK 99801, 907-586-5880
TSAGC Webinar May 7, 2014
Maximizing Revenue and Minimizing Costs
Slide 3
Tribal Opportunities: As a . . .
• Health Provider
• IHCIA § 206 – Third Party Recovery
• IHCIA § 401 – Reimbursement from Medicare, Medicaid & CHIP
• IHCIA § 408 – Right to Reimbursement from Federal Programs,
including VA and DoD under § 405(c)
• ARRA § 5006 – Medicaid Cost-Sharing Protection
• ACA §§ 1402(d) and 2901(a) – Exchange Plan Cost-Sharing Protections
• IHCIA § 813 – FTCA for Services Provided to Non-Beneficiaries
• Electronic Health Record Incentive Payments
• ARRA § 5006 – Deemed Participating PPO by Medicaid Managed Care
Plans and BBA of 1997 – No Mandatory Enrollment of AI/ANs in
Medicaid Managed Care Plans
• ACA § 2202 Medicaid Presumptive Eligibility by Hospitals
Sonosky, Chambers, Sachse, Miller & Munson, LLP
TSAGC Webinar May 7, 2014
Maximizing Revenue and Minimizing Costs
Slide 4
I/T/U Roles and Opportunities
• Purchaser of Health Services/Contract Health Services
• ARRA § 5006 and ACA §§ 1402(d) and 2901(a) – Cost-Sharing
Protections
• ACA § 2901(b) – Payer of Last Resort (25 U.S.C. § 1623(b))
• MMA § 506 – Medicare Like Rates
• Purchaser of Health Coverage for IHS Beneficiaries
•
•
•
•
IHCIA § 402 – Authority to Purchase Coverage or Health Services
ACA Exchange Plan Coverage
Medicare Part D
ACA Exchange Plans
Sonosky, Chambers, Sachse, Miller & Munson, LLP
TSAGC Webinar May 7, 2014
Maximizing Revenue and Minimizing Costs
Slide 5
I/T/U Roles and Opportunities
• Provider of Health Coverage for Employees (Indian and NonIndian)
• IHCIA § 409 – Federal Employee Health Benefit Plan
• ACA Medicaid Expansion
• Direct Delivery of Services
• Advocate for AI/ANs
AND, most of these lists are not complete!!!
There are other opportunities.
Sonosky, Chambers, Sachse, Miller & Munson, LLP
TSAGC Webinar May 7, 2014
Maximizing Revenue and Minimizing Costs
Slide 6
But, Let’s Focus
Most rights are not self-enforcing.
Generating revenue and achieving savings require affirmative
action and constant monitoring.
No one part of the Tribe can do the work in isolation from the
rest.
Sonosky, Chambers, Sachse, Miller & Munson, LLP
TSAGC Webinar May 7, 2014
Maximizing Revenue and Minimizing Costs
Slide 7
Do You Know
Who Is an “Indian” for What Purpose?
See, Handout:
Indian Health Services, Medicaid,
Affordable Care Act:
Who is Eligible for What?
Sonosky, Chambers, Sachse, Miller & Munson, LLP
302 Gold Street, Suite 201, Juneau, AK 99801, 907-586-5880
TSAGC Webinar May 7, 2014
Maximizing Revenue and Minimizing Costs
Slide 8
Questions?
This is your first chance; there will be others.
Sonosky, Chambers, Sachse, Miller & Munson, LLP
302 Gold Street, Suite 201, Juneau, AK 99801, 907-586-5880
TSAGC Webinar May 7, 2014
Maximizing Revenue and Minimizing Costs
Slide 9
You Can’t Collect, If You Don’t Bill
Must haves:
• Billing system or contractor
• Trained staff – coding, compliance, providers,
billers
• Good negotiators
• A business focus
And, even then there are challenges
Sonosky, Chambers, Sachse, Miller & Munson, LLP
302 Gold Street, Suite 201, Juneau, AK 99801, 907-586-5880
TSAGC Webinar May 7, 2014
Maximizing Revenue and Minimizing Costs
Slide 10
Sec. 206 THIRD PARTY RECOVERY
S. 1790 S. 125; 25 U.S.C. § 1621e
*Right to recover reasonable charges (rather than
reasonable expenses) or highest amount the payor would
pay a non-governmental provider
• from insurance companies, HMOs, employee benefit plans, and
tortfeasors, and any other responsible or liable third party
• Allows THOs to use the Federal Medical Care Recovery Act
• Allows self-insured tribes to authorize payment to IHS
• Allows THO to recover costs and attorney’s fees if prevail
Status: Tribal health programs are increasingly aware of the importance of
pursuing recovery as required by law; many insurers are unaware of the
rules or actively resist. Litigation occurring to enforce tribal rights.
Sonosky, Chambers, Sachse, Miller & Munson, LLP
TSAGC Webinar May 7, 2014
Maximizing Revenue and Minimizing Costs
Slide 11
Some Insurers Don’t Want to Pay
ANTHC v. Premera
Federal District Court for Alaska ruled on Summary
Judgment motion that if an Indian tribe agreed to accept
payments lower than its billed charges by contract (for
example, discounting for preferred provider status), then
the payment contract controls.
Sonosky, Chambers, Sachse, Miller & Munson, LLP
TSAGC Webinar May 7, 2014
Maximizing Revenue and Minimizing Costs
Slide 12
What If There Is No Contract
In the absence of a payment contract, the Court also ruled
that the Indian health program is entitled to the higher of:
(1) its reasonable charges or
(2) an amount higher than its reasonable charges to the
same extent non-governmental providers are entitled to
receive that rate. Minimum payment under Alaska
insurance regulations (80th percentile of charges in the
geographic area) was the example used by the Court in
its decision.
Sonosky, Chambers, Sachse, Miller & Munson, LLP
TSAGC Webinar May 7, 2014
Maximizing Revenue and Minimizing Costs
Slide 13
What Hasn’t Been Ruled On
There is no ruling yet on the extent to which (if any) insurers
can reduce payments because the Indian health program is
not part of its preferred network (some reduce by as much
as 60%) (Premera, for example).
We think this is impermissible since Section 206 (1) allows
recovery of “reasonable charges billed,” not discounted “out
of network” rates, and (2) Section 206 covers managed care
organizations, which by definition require individuals to stay
in network (argument not made yet and not rules on yet).
Sonosky, Chambers, Sachse, Miller & Munson, LLP
TSAGC Webinar May 7, 2014
Maximizing Revenue and Minimizing Costs
Slide 14
What’s Likely to Happen
This litigation will take time. Efforts at mediation failed
completely. Premera is simply not accepting the Court
means what was said in the summary judgment ruling. It
has filed two more motions trying to get the case dismissed.
In the meantime, there has been discovery, and may still
require further litigation about the facts, more motion
practice, and possibly appeals.
Don’t hold your breath!
Sonosky, Chambers, Sachse, Miller & Munson, LLP
TSAGC Webinar May 7, 2014
Maximizing Revenue and Minimizing Costs
Slide 15
What Can You Do?
Keep billing (or start if you’ve stopped). You won’t
get paid if you don’t file a claim.
Keep charges up-to-date. Charges are usually higher
than what insurers pay routinely. You won’t know
what the insurers are paying others, but you can know
about your own charges.
Sonosky, Chambers, Sachse, Miller & Munson, LLP
TSAGC Webinar May 7, 2014
Maximizing Revenue and Minimizing Costs
Slide 16
What Can You Do? continued
Work claims. Denials are being routinely issued by
some insurers that count on the Indian health system
being too overwhelmed to refile and demand
payment.
Do not enter into any form of contract unless you are
willing to accept the payment rates. The District
Court for Alaska has ruled that if you’ve agreed to
certain rates, you are stuck with them.
Sonosky, Chambers, Sachse, Miller & Munson, LLP
TSAGC Webinar May 7, 2014
Maximizing Revenue and Minimizing Costs
Slide 17
What Can You Do? continued
Read and review ALL the terms of any Agreement with an
Insurer. Be sure the agreements do not have other terms
that compromise the Indian health program or Tribe.
And, this includes the CMS Tribal Addendum.
Although there is a lot in it that is really helpful, there are
provisions that may be problematic for your tribe.
IF YOU SIGN AN AGREEMENT, BE SURE YOU ARE PREPARED
TO LIVE WITH IT.
Sonosky, Chambers, Sachse, Miller & Munson, LLP
TSAGC Webinar May 7, 2014
Maximizing Revenue and Minimizing Costs
Slide 18
Using Cost Sharing Protections to Generate
Revenue and Achieve Savings
• IHCIA Sec. 4(5) defines “Contract Health Services” (CHS) to include
referrals without commitment to pay, as well as those where there the
I/T/U will take responsibility for payment.
• No Medicaid Premiums or Cost Sharing – ARRA 5006; 42 USC 1396o(j).
•
•
•
•
AI/ANs referred by CHS to any provider are not responsible for any cost
sharing.
The provider payment may not be reduced by the amount of the cost sharing.
Applies to Medicaid Expansion
Cost Sharing Protections under Exchange Plans – ACA §§ 1402(d) and
2901(a): Must verify status with each plan and potential covered person
• Indians under 300% of poverty, enrolled in any Exchange plan, are exempt from
cost sharing (25 U.S.C. § 1623(a))
• No cost sharing for services provided by I/T/U and no deduction in payments to
I/T/U
• Qualified Health Plan will be paid by HHS for the cost sharing
Sonosky, Chambers, Sachse, Miller & Munson, LLP
TSAGC Webinar May 7, 2014
Maximizing Revenue and Minimizing Costs
Slide 19
COST AVOIDANCE
Medicare Like Rates
Basic Rule Effective July 5, 2007 – A Medicare enrolled hospital may not accept
more than a Medicare Like Rate for services provided to an American Indian or Alaska
Native (AI/AN) for any medical care purchased under the contract health services
(CHS) program or a UIO purchase for an urban Indian. If the I/T/U has an agreement
that provides for lower payment for the CHS, then the hospital must accept the lower
amount.
BUT, many tribal programs are still not taking advantage of this. If
not, is it too late? We don’t think so. But, there will be work involved.
•
•
•
•
Reprice at least a sample of claims
Make a request to the hospital to work out a settlement of past claims
Follow-up if the hospital doesn’t cooperate
BEGIN REPRICING IMMEDIATELY SO THAT YOU DO NOT CONTINUE TO PAY
MORE THAN IS REQUIRED
Negotiate MLR withSonosky,
otherChambers,
providers
Sachse, Miller & Munson, LLP
TSAGC Webinar May 7, 2014
Maximizing Revenue and Minimizing Costs
Slide 20
Don’t Leave Money on the Table!
Medicare Quality Initiatives require affirmative
action – otherwise, payment levels may be reduced.
o Physician Quality Reporting System (PQRS)
o Electronic Prescribing (eRX)
o Ambulatory Surgery Center (ASC) Quality Reporting
See, “Reimbursement and Billing: Medicare Incentive Payments,”
Presentation by Sherrie Varner, Choctaw Nation of Oklahoma, Medicare
Policy Analyst & Affordable Care Implementation Team, at NIHB Annual
Consumer Conference, August 2013.
Sonosky, Chambers, Sachse, Miller & Munson, LLP
TSAGC Webinar May 7, 2014
Maximizing Revenue and Minimizing Costs
Slide 21
Questions?
This is your second chance; there will be others.
Sonosky, Chambers, Sachse, Miller & Munson, LLP
302 Gold Street, Suite 201, Juneau, AK 99801, 907-586-5880
TSAGC Webinar May 7, 2014
Maximizing Revenue and Minimizing Costs
Slide 22
YOU’VE GOT THE BASICS, WHAT’S NEXT?
Sonosky, Chambers, Sachse, Miller & Munson, LLP
302 Gold Street, Suite 201, Juneau, AK 99801, 907-586-5880
TSAGC Webinar May 7, 2014
Maximizing Revenue and Minimizing Costs
Slide 23
Expand Services
More and Better Health Care and More $$$
ACA requires health plans to pay for more prevention and wellness
• Requires plans issued after 3/23/10 to provide certain preventive
care without cost
• Specified screenings for adults with certain conditions such as
high blood pressure or cholesterol, diabetes, and cancer
• Increases Federal share for certain preventive services if States
do not charge co-pays
• Required Medicaid to cover tobacco cessation to pregnant
women
If you aren’t providing these services, you are missing an opportunity
to improve health status and generate revenue.
TRIBAL HEALTH PROGRAMS – include all your health programs in your
ISDEAA funding agreement so you get the benefit of FTCA coverage and more
certain reimbursement.
Sonosky, Chambers, Sachse, Miller & Munson, LLP
TSAGC Webinar May 7, 2014
Maximizing Revenue and Minimizing Costs
Slide 24
More Expansion
• Serve tribal employees
• Serve other people in the community
• Expand direct services when the cost of CHS or
claims exceed the cost of providing the services
directly
Sonosky, Chambers, Sachse, Miller & Munson, LLP
302 Gold Street, Suite 201, Juneau, AK 99801, 907-586-5880
TSAGC Webinar May 7, 2014
Maximizing Revenue and Minimizing Costs
Slide 25
eliminate silos
inside and outside the Tribe
Sonosky, Chambers, Sachse, Miller & Munson, LLP
302 Gold Street, Suite 201, Juneau, AK 99801, 907-586-5880
TSAGC Webinar May 7, 2014
Maximizing Revenue and Minimizing Costs
Slide 26
Employer: Consider Options
• Federal Employee Health Benefit Plan
• Risk based policies vs. self-insured coverage
• Be your own provider and keep the money within
the Tribe and maximize opportunities to improve
worker health
Sonosky, Chambers, Sachse, Miller & Munson, LLP
302 Gold Street, Suite 201, Juneau, AK 99801, 907-586-5880
TSAGC Webinar May 7, 2014
Maximizing Revenue and Minimizing Costs
Slide
FEHB –
An Option for Employee Insurance Coverage
For more information: See Office of Personnel Management,
Tribal Federal Employees Health Benefits Handbook
Highlights, available at http://www.opm.gov/healthcareinsurance/indian-tribes/reference-materials/handbook-highlights.pdf
OPM webpage for Tribes: http://www.opm.gov/healthcareinsurance/indian-tribes/health-insurance/
Dear Tribal Leader Letter: http://www.opm.gov/healthcareinsurance/indian-gtribes/hr-personnel/outreachdocuments/122011letter.pdf (Dec. 21, 2011)
Frequently Asked Questions: http://www.opm.gov/healthcareinsurance/indian-tribes/faqs
2014 Rates just announced: See,
http://www.opm.gov/healthcare-insurance/healthcare/planinformation/premiums/#url=Premiums
Sonosky, Chambers, Sachse, Miller & Munson, LLP
TSAGC Webinar May 7, 2014
Maximizing Revenue and Minimizing Costs
Slide 28
Tribal Health Provider
Can be part of the solution to Tribal health costs!
But, you have to overcome the myths. Is it really
true:
• that you always have to wait for an appointment
or when you arrive for an appointment?
• the quality isn’t as good as if you have private
insurance?
• the services never pay for themselves?
NO! But, it doesn’t matter if that is the general
perception.
Sonosky, Chambers, Sachse, Miller & Munson, LLP
TSAGC Webinar May 7, 2014
Maximizing Revenue and Minimizing Costs
Slide
Employer Strategies
Avoid Penalties
• For failure to provide required summaries (up to
$1000 for each plan beneficiary to whom not
provided)
• For failure to offer coverage
• Don’t offer too much coverage (Cadillac Plans –
beginning 2018 if value of premiums exceeds $10,200
for individual or $27,500 for family (subject to
inflation adjustments), a 40% excise tax may be
imposed
Sonosky, Chambers, Sachse, Miller & Munson, LLP
302 Gold Street, Suite 201, Juneau, AK 99801, 907-586-5880
TSAGC Webinar May 7, 2014
Maximizing Revenue and Minimizing Costs
Slide
What If Your State Hasn’t Adopted Medicaid
Expansion? BE AN ADVOCATE
1. Don’t give up. There is no deadline.
2. Get your facts in line about the benefits –
economic to the State, reducing uncompensated
care, and better health for otherwise uncovered
individuals.
3. Get together with other advocates for Expansion
and not just the hospitals.
4. Try to keep the issue alive. Don’t let it disappear.
Sonosky, Chambers, Sachse, Miller & Munson, LLP
302 Gold Street, Suite 201, Juneau, AK 99801, 907-586-5880
TSAGC Webinar May 7, 2014
Maximizing Revenue and Minimizing Costs
Slide 31
Ideas for a Work Plan
• Health planning work group: Council, Finance, Human
Resources, Health Department, legal
• Catalog all health care provided: directly and through
self-insurance, CHS, extended benefits to members,
purchased insurance, reinsurance
• Make a timeline of when new requirements and costs
may hit so you are ahead of them
• Evaluate impact of new requirements and opportunities
• Strategize options to reduce cost, improve impact of funds
spent, increase revenue
• Influence policy: review all proposed State Medicaid rules
and State Plan Amendments and Comment
• Don’t move to fast, but don’t wait too long!
Sonosky, Chambers, Sachse, Miller & Munson, LLP
TSAGC Webinar May 7, 2014
Maximizing Revenue and Minimizing Costs
Slide 32
Questions?
This is the last chance for this presentation, but all
questions about maximizing revenues and
minimizing costs are welcome. You can also send
questions via the internet on the Health Reform
page for the Self-Governance Communications and
Education (SGCE) website:
http://www.tribalselfgov.org/____NEWSGCE/___healthcare/Blog_page/healthblog2.html
Sonosky, Chambers, Sachse, Miller & Munson, LLP
302 Gold Street, Suite 201, Juneau, AK 99801, 907-586-5880
TSAGC Webinar May 7, 2014
Maximizing Revenue and Minimizing Costs
Slide 33
References
Where do I find these laws?
What do the acronyms mean?
Sonosky, Chambers, Sachse, Miller & Munson, LLP
302 Gold Street, Suite 201, Juneau, AK 99801, 907-586-5880
TSAGC Webinar May 7, 2014
Maximizing Revenue and Minimizing Costs
Slide 34
Citations for the Wonks
ACA = Patient Protection and Affordable Care Act, Pub. L. 111-148
ARRA = American Recovery and Reinvestment Act of 2009, Pub. L. 1115
(Feb. 2009)
CHIPRA = Children’s Health Insurance Program Reauthorization Act, Pub.
L. 111-3 (Feb. 2009)
IHCIA = Indian Health Care Improvement Act, Pub. L. 94-437, as
amended, most recently by ACA § 10221, which enacted by reference S.
1790, as reported out of the Senate Committee on Indian Affairs in
December 2009, with four amendments
ISDEAA = Indian Self-Determination & Education Assistance Act, Pub. L.
93-437, as amended
Sonosky, Chambers, Sachse, Miller & Munson, LLP
TSAGC Webinar May 7, 2014
Maximizing Revenue and Minimizing Costs
Slide
Even More for Wonks
MMA = Medicare Prescription Drug, Improvement, and Modernization
Act of 2003, Pub. L. 108-173, amending § 1866(a)(1) of the Social
Security Act. See, Sec. 506, codified at 42 U.S.C. § 1395cc(a)(1)(U), and
regulations found at 42 C.F.R. § 136 and C.F.R. Title 42, Part 489,
provider agreements and supplier approval.
Sonosky, Chambers, Sachse, Miller & Munson, LLP
TSAGC Webinar May 7, 2014
Maximizing Revenue and Minimizing Costs
Slide
Acronyms for IHCIA and ACA
ACA = Patient Protection and Affordable Care Act, Pub. L. 111-148
ARRA = American Recovery and Reinvestment Act of 2009, Pub. L. 1115 (Feb. 2009)
AI/AN = American Indian/Alaska Native
APTC = Advance Premium Tax Credit
BBA = Balanced Budget Act of 1997
CCIIO = Center for Consumer Information and Insurance Oversight (part of CMS; used to be OCIIO)
CHIP (or CHP) = Child Health Insurance Program
CHIPRA = Children’s Health Insurance Program Reauthorization Act, Pub. L. 111-3 (Feb. 2009)
CHSDA = Contract Health Service Delivery Area
CMS = Centers for Medicare & Medicaid Services (agency within Dept. of Health & Human Services)
EHB = Essential Health Benefits
FEHB = Federal Employee Health Benefit Plan
FEGLI = Federal Employees Group Life Act
FPL = Federal Poverty Level
IRC = Internal Revenue Code
ISDEAA = Indian Self-Determination & Education Assistance Act, Pub. L. 93-437, as amended
I/T/U = Indian Health Service/Tribal Health Program/Urban Indian Organization
Sonosky, Chambers, Sachse, Miller & Munson, LLP
302 Gold Street, Suite 201, Juneau, AK 99801, 907-586-5880
TSAGC Webinar May 7, 2014
Maximizing Revenue and Minimizing Costs
Slide 37
More Acronyms
MAGI = Modified Adjusted Gross Income
MEDPAC = Medicaid and CHIP Payment and Access Commission
MMA = Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Pub. L. 108-173 (Dec.
2003)
MMPC = Medicare/Medicaid Policy Committee of the NIHB
NIHB = National Indian Health Board
OCIIO = Office of Consumer Information and Insurance Oversight in HHS
QHP = Qualified Health Plan
PCIP = Pre-Existing Condition Insurance Plan (often referred to as “high risk pool” plan)
SHOP = Small Business Health Options Program
TTAG = Tribal Technical Advisory Group to the CMS
TrOOP = True Out-of-Pocket costs applicable to Medicare Part D
UIO = Urban Indian Organization, as defined in IHCIA Sec. 4(29)
VA = Department of Veterans Affairs
And, there will be lots more!
Sonosky, Chambers, Sachse, Miller & Munson, LLP
302 Gold Street, Suite 201, Juneau, AK 99801, 907-586-5880
TSAGC Webinar May 7, 2014
Maximizing Revenue and Minimizing Costs
Slide 38
Presenter
Myra M. Munson is a partner in the Juneau office of Sonosky, Chambers, Sachse, Miller &
Munson LLP, which specializes in representing tribal interests in Alaska and throughout the
United States. She earned her bachelor's degree from the University of Alaska Fairbanks in
1972 and her law degree and master's degree in social work with honors from the University
of Denver in 1980. After serving as Alaska Commissioner of Health and Social Services from
1986 to 1990, Ms. Munson joined the Sonosky Law Firm LLP where her practice has
emphasized self-determination and self-governance, the Indian Health Care Improvement Act
(IHCIA), Medicaid and other third-party reimbursement issues, and other health program
operations issues. She was a technical advisor to the IHCIA National Steering Committee for
over 10 years; assisted in drafting and editing substantial sections of the reauthorization; and
testified before the Senate Committee on Indian Affairs. Ms. Munson is also a member of the
National Indian Health Board Medicare & Medicaid Policy Committee, and a technical advisor
to the Centers for Medicare and Medicaid Services Tribal Technical Advisory Group. She has
been conducting extensive training on the Affordable Care Act and IHCIA since their passage
and serves as a consultant to the National Indian Health Board with regard to training on and
implementation of these new laws. In 2003, Ms. Munson was given the Denali Award by the
Alaska Federation of Natives. and in 2009 the Healthy Alaska Native Foundation awarded her
with its President’s Award.
Sonosky, Chambers, Sachse, Miller & Munson, LLP
302 Gold Street, Suite 201, Juneau, AK 99801, 907-586-5880
TSAGC Webinar May 7, 2014
Maximizing Revenue and Minimizing Costs
Slide 39