Maryland AAHAM Education Conference January 17, 2014 Linthicum, MD Managed Care Contracting Under ICD-10 Rob Borchert, MBA, CRCE-I – Best Practice Associates Lorrie Borchert, CPC, CRCE-I – Best Practice Training Institute Learning Objectives • • • • • • • Review of ICD-10 Impacts! Review of ACA components! (2014 and beyond) Discussion of various Contract Types! Discussion of new Exchange Contracts! How to perform various analyses! What will payors do? What should YOU do? @Best Practice Associates 2 ICD Code Difference CM - Clinical Modification PCS- Procedure Coding System 100000 80000 90000 70000 80000 60000 70000 50000 60000 40000 50000 30000 40000 20000 30000 10000 20000 0 Series1 10000 1 9 ICD ICD2 10 13000 68000 0 Series1 @Best Practice Associates 1 ICD-9 2 10 ICD 11000 87000 3 Mapping Between Old And New Systems • General equivalence maps (GEMs) between ICD-9CM and ICD-10-CM/PCS have been developed • GEMs do NOT equal crosswalks • Reimbursement map added to CMS web site in 2009 – – – – Intended for use by payors Temporary mechanism Allows claims processing by legacy systems Allows for data collection for reimbursement changes • Maps should NOT be used for coding medical records @Best Practice Associates 4 Mappings @Best Practice Associates 5 GEMs Mapping @Best Practice Associates 6 CMS GEMS vs. CMS Reimbursement Mappings Source: Deloitte Consulting presentation “Do Not Underestimate ICD-10’s Impact on @Best Practice Associates Population Health Management” at the Forum 10 in Washington, DC 10/15/10 7 When should GEMS be used? • To convert databases such as: – – – – – – – – Payment systems Payment and coverage edits and policies Risk adjustment logic Quality measures Disease management programs Utilization/case management systems Financial modeling Variety of research applications involving trend data • To translate coded data for comparing data across transition period @Best Practice Associates 8 When should GEMs NOT be used? • When you have access to the medical record? • When you have access to text descriptions or clinical terms describing diagnosis or procedure • When a small number of codes are being converted • GEMs should NOT be used for coding medical records!!!! @Best Practice Associates 9 Sports Medicine Hit by a ball - ICD-9-CM code: E917.0 ICD-10-CM possible code • • • • • • • • • W21.00 – Struck by hit or thrown ball, unspecified type W21.01 – Struck by football W21.02 – Struck by soccer ball W21.03 – Struck by baseball W21.04 – Struck by golf ball W21.05 – Struck by basketball W21.06 – Struck by volleyball W21.07 – Struck by softball W21.09 – Struck by other hit or thrown ball @Best Practice Associates 10 ICD-10-PCS Code Structure ICD-10 PCS Code Structure: Root Operation Section 1 2 Body System 3 Approach 4 5 Body Part @Best Practice Associates 6 Qualifier 7 Device 11 ICD-10-PCS Example Interphalangeal fusion of right great toe, percutaneous pin fixation OSGP34Z Section Med/Surgical 0 Body System Lower Joints S Root Operation Fusion G Body part Toe Phalangeal Joint - Right P Approach Percutaneous 3 Device Internal Fixation Device 4 Qualifier None Z @Best Practice Associates 12 @Best Practice Associates 13 Impacts to People Source: AAPC website @Best Practice Associates 14 Impacts to Process • Documentation practices • Productivity and efficiency practices • Contracts and business processes • HIM practices • Practice management processes • Budget • Payment conversions • System logic and edits • Claims edits • Disease & Utilization management @Best Practice Associates 15 Impacts to Process @Best Practice Associates 16 Impacts to Technology • • • • • • • • IT system changes Upgrade software Modified field lengths Modified system logic Update superbills/encounter forms and databases Data reporting elements Submitting ICD-9 and ICD-10 codes Retain access to historical coded data in ICD-9 format @Best Practice Associates 17 Revenue Cycle Impacts Clinical Business Process/ Patient Access Patient Access Services PreRegistration Patient Financial Services Claims Processing Charge Capture Entry Scheduling Registration Account Resolution Financial Counseling Coding Assignment Pricing Payment Posting Clinical Intervention Test Order “Optional” Clinical Doc. Scheduling IT Applications Charge/Coding Integrity HIS (including CPOE) Claims Clearinghouse HIM Patient Accounting Utilization Management Case Management Patient Accounting Performance Measurement Medium Impact to process and training Large impact to process and training @Best Practice Associates 18 Contract Management and Insurance Verification • Building coverage patterns from TPP contracts • Specific specialty definitions of both CPT and diagnosis (Case Rates) • HIPAA Transaction sets • Educating and Training staff for optimum coverage in identifying both POA and principal reason for admission (medical necessity) • TPP systems monitoring @Best Practice Associates 19 ICD-10 Effect on Payor Reimbursements • Independent analysis of some of the most common reimbursement arrangements identified conversion challenges that may modify some payor and provider reimbursement arrangements, while for others the effect will be minimal. • Solutions to these situations need to be tailored to your specific environment; however, you will want to review the possibilities identified in the analysis outlined in the table below. • In cases such as diagnosis-related group carve outs where codes have a relatively small impact on reimbursement formulas, most payors will likely experience few conversion problems. @Best Practice Associates 20 ICD-10 Impact on Payor Reimbursements Common Reimbursement Arrangements DRGs and other case rates Potential ICD-10 Impact Identified by Independent Analysis Hospitals, government, and commercial payors Code focus: ICD-9 and procedure codes 1. ICD-9 diagnosis and procedure codes are the basis for diagnosis-related groups (DRG) classifications. 2. Using General Equivalence Mappings (GEMs), a number of ICD-10 codes did not map easily to the MSDRGs (inpatient reimbursement); the clinical review process was required to complete the conversion process. GEMs are a tool to help find matches between ICD-9 and ICD-10 codes. 3. The ICD-10 MS-DRGs will likely produce some different reimbursement results compared to ICD-9-based MS-DRGs, for example: a. Clean mapping problems b. Service frequency, billed code volume, impact on dollars c. Clarity of ICD-10 code may produce a different code assignment based on the original ICD-9 code d. Dollar and volume magnitude related to the changes to Complications Comorbidities (CC)/ Major Complications Comorbidities (MCC) lists are unknown 4. The Inpatient Psychiatric Facility Prospective Payment System for psychiatric facilities and Medicare Severity Long-term Care DRG for long-term hospitals both use the same MS-Grouper and will be similarly affected. 5. When applying CMS-designed ICD-10 MS-DRGs to a commercial population, the case mix may vary more than the Medicare population does. @Best Practice Associates 21 ICD-10 Impact on Payor Reimbursements Common Reimbursement Arrangements Potential ICD-10 Impact Identified by Independent Analysis Risk-adjusted Reimbursement Medicare/Medicaid programs Code focus: Hierarchical Condition Categories (HCCs) and Rx-HCCs 1. Although more than 5,500 ICD-9 diagnosis codes on the HCC and Rx-HCC models have no ICD-10 map, HCC developers will be able to include the conditions in the ICD-10 HCC without altering the intent. The largest potential impact is that more than 1,000 HCC ICD-9 codes have more than one ICD10 option. 2. The ICD-10 transition impact will be quite evident in situations where one ICD-10 code maps to more than one ICD-9 code and either the ICD-9 codes do not map at all to a HCC, or to the same HCC. DRGs/inpatient care rate carve-out, passthrough or add-on technology procedure or diagnosis Commercial insurers Code focus: DRG inpatient payment carve-outs where payment is negotiated 1. Diagnoses carve-outs are typically paid by broad category with little reliance on coding specifics to differentiate payment levels. 2. Expect minimal impact on procedural coding because inpatient patient carve-out procedures and technology are often reimbursed as a percentage of charges. Outpatient procedures are reimbursed based on Current Procedural Terminology (CPT) codes where additional information is not needed to pay a claim. Episode-based Reimbursement Demonstrations (ACE – Acute Care Episode) and other pilots While there have not been many systems reimbursing on episodes of care based on ICD-9 codes, the advent of ICD-10-specific codes will likely accelerate the development of these payment types. @Best Practice Associates 22 ICD-10 Impact on Payor Reimbursements Common Reimbursement Arrangements Potential ICD-10 Impact Identified by Independent Analysis Performance-based Reimbursement Health plans, Medicare Pay for Performance (P4P) Code focus: Healthcare Effectiveness Data and Information Set (HEDIS) and similar performance measures 1. The most common structures are based on either reaching specified performance level or degree of improvement. The transition to ICD-10 may affect HEDIS-based outcomes as HEDIS uses ICD-9 diagnosis and procedure codes along with other codes such as CPT and revenue codes. In the case of immunization codes, ICD-9 codes are more specific than the ICD-10 mapping (five ICD-9 codes would now map to two ICD-10 procedure codes). Because these ICD-10 codes are less specific, the small portion of immunizations occurring in an inpatient setting will be unidentifiable under ICD-10, and this may affect performance measurement. Hospital Billed Charges Hospitals Code focus: billed charges, CPT/HCPCS 1. The conversion to ICD-10 should have minimal impact on billed charges because predecessor ICD-9 codes were not used to create the charges. Usual and Customary Reimbursement (UCR) Payors, hospitals, and providers Code focus: diagnosis codes 1. Diagnosis codes are used to help determine the payment rate and facilities’ qualification as inpatient rehabilitation facilities (IRFs). Therefore, the initial conversion to ICD-10 will have some impact on reimbursement based on IRF-Prospective Payment System (PPS). The challenge will be in determining which ICD-10 codes are the qualifying codes that should be included in the IRF logic. 2. The increased specificity of ICD-10 codes will influence the IRF-PPS model in the future. @Best Practice Associates 23 ICD-10 Impact on Payor Reimbursements Common Reimbursement Arrangements Other Reimbursement Arrangements Potential ICD-10 Impact Identified by Independent Analysis Brief summary Resource Utilization Groups (RUGs): Minimal if any impact on skilled nursing facilities and RUGs. Home Health Resource Groups (HHRGs): Although many of the HHRG diagnostic categories are broad, there will be some instances where HHRG assignment for the same condition may vary under ICD-10 compared to ICD-9 diagnosis codes. Possible future conversion of the CPT/HCPCS codes to ICD-10 PCS parallel with the CPT/ HCPCS codes. Source: Zenner, Patricia. ICD-10 Impact on Provider Reimbursement. Milliman, 2010. Retrieved from http://publications.milliman.com/publications/health-published/pdfs/icd-10-impact-provider.pdf. @Best Practice Associates 24 Examples of I-9 to I-10 Conversions Crohn’s Disease ICD – 9 (4) ICD – 10 (28) Regional enteritis of small intestine 555.0 K50.00 Regional enteritis of large intestine 555.1 PLUS an Regional enteritis of small intestine w/ large intestine 555.2 ADDITIONAL Regional enteritis of unspecified site 555.9 27 CODES ICD – 9 92.27 Implementation or insertion of radioactive elements ICD-10 PCS 261 PCS codes for Anatomical sites specified 21 distinct Approaches @Best Practice Associates 25 MCC/CC Category Conversion Conversion Summary MCC CC Total ICD-9-CM Codes on List 1,592 3,427 5,019 ICD-10 CM codes Auto-translated 3,152 13,594 16,845 DRG Description # ICD-9 codes 291-293 Heart Failure & Shock 27 20 231-236 Coronary Bypass 9 232 250-251 Percutaneous Cardiovascular Procedure without Stent 8 136 258-259 Cardiac Pacemaker Device Replacement 6 14 533-534 Fracture of Femur 14 273 @Best Practice Associates # ICD-10 codes 26 Managed Care Today • Fully examine the rates you have today!!!!! – MSDRG rates – Case Rates for inpatient – APC/APG Rates for outpatient surgery and ancillary support services – Per diem rates for various services – Percent of charge rates for various services – Discount off Medicare rates @Best Practice Associates 27 Managed Care Tomorrow • Insurance Products under ACA: – No ability to deny or limit coverage for pre-existing conditions – No lifetime limits on benefits – No ability to cancel coverage without proof of fraud – Ability of patients to demand reconsideration of health plan decision to deny payment for test or treatment – includes an external appeal process @Best Practice Associates 28 Managed Care Tomorrow • Insurance Products under ACA: – Cost-free preventive services – access to screenings/vaccinations & counseling without deductible or co-insurance – Kids on parent’s plan until reach age of 26 – Must be able to choose your primary care physician – no need for referral to OB/GYN – Use nearest ED without penalty or no requirement to get prior approval and no higher deductible or co-insurance for out-of-network ED visits @Best Practice Associates 29 @Best Practice Associates 30 @Best Practice Associates 31 Managed Care Tomorrow • What payers will seek from providers under BOTH Affordable Care Act (ACA) and ICD-10: • • • • • medical decision making models capitation models quality measures and payments bundling payment patient-centered medical homes • As a provider, can YOU bring your Quality and Cost factors to the table FIRST? @Best Practice Associates 32 10 Considerations for Building a Pricing Strategy Make margin decisions NOW Gather competitive pricing from all sources Use market research to understand trade-offs consumers are willing to make between price versus service Assess the value to you of a loss leader Calculate customer value profile to include transaction and downstream Scrutinize cost reports for accuracy Inventory your “soft selection” factors “Sell” the organization’s pricing strategies to physicians and staff Identify and follow enterprise metrics Set your market position @Best Practice Associates 33 Medical Decision Making Models • Not all services are created equal • We do too many unnecessary things and don’t do enough of the good stuff • If something costs more, you are less likely to buy • If something costs less, you are more likely to buy • If you have already paid, you feel entitled to it • Patients are interested in what happens to them • The best treatment for a given individual may depend on their own goals and values @Best Practice Associates 34 Value-Based Benefit Design Low Cost – High Value • Identify high value services that are underused – Screening – Prevention – Evidence based chronic disease management – Prenatal care • Reduce or eliminate cost to access • Offer to payor for increased market share Costs more – Learn more • Identify preference sensitive and supply sensitive services for which evidence suggests – – – – Coronary revascularization Back surgeries Cross sectional imaging Large joint replacements • Center of Clinical Excellence • Patient Preference = High Value • Should Cost More @Best Practice Associates 35 Value-Based Benefit Design No Co-Pay – High Value • • • • • • • • Immunizations Pregnancy Hypertension Asthma Diabetes Coronary Heart Disease Congestive Heart Failure Depression Center of Clinical Excellence = High Value • Surgery for BPH • Arthroscopy for OA at knee • Knee and hip replacement surgery • Hysterectomy for DUB, fibroids • Some CT, MRI and PET scans • Invasive treatments for angina • Endoscopy for GERD @Best Practice Associates 36 Capitation • • • • • Utilization Visits/PMPM Days/1000 OP Procedures/1000 Referrals/1000 Lab/VISIT Unit Cost • Cost per IP Day – Medical – Surgical – ICU; Intensive Care • Cost per Consultant • Cost per IP service Capitation = Fixed Payment per Member per Month (PMPM) for Block of Covered Services @Best Practice Associates 37 Shared Decision Making • Provides an incentive to patients to use patient decision aids that intersect with affected areas • Make entire library of patient decision aids available to patients and providers @Best Practice Associates 38 Product Pricing on the Health Benefit Exchange • New population – individual and small group plans • Little to no experience regarding the populations • Some states will have only 1 plan on the exchange, others, like Colorado, may have as many as 800 plans with 17 carriers participating • Some plans may be trying to acquire market share by offering very low cost plans (less than $200/month for basic benefits) • May be some new entrants into the health insurance market in your state @Best Practice Associates 39 Key Aspects of Quality Measures and Payments • Share patient information across the continuum of care and across the network of providers – while maintaining confidentiality; • Capture and compute accurate costs of care; • Track clinical outcome data in relationship to services provided; • Assure longitudinal collection and storage of patient information; • Support the use of clinical protocols and guidelines to improve quality and contain costs. @Best Practice Associates 40 Bundled Payment Models • Model One: Retrospective Acute Care Hospital Stay ONLY • Model Two: Retrospective Acute Care Hospital Stay PLUS Post-Acute Care (end either 30, 60, or 90 days post; can select up to 48 clinical condition episodes) @Best Practice Associates 41 Bundled Payment Models • Model Three: Retrospective Post-Acute Care Only (end either 30, 60, or 90 days post; can select up to 48 clinical condition episodes) • Model Four: Acute Care Hospital Stay Only (hospital, physicians, and others) @Best Practice Associates 42 Bundled Payment Models Flexibility • Under models where there are choices of episodes of care to be bundled, organizations can choose which episodes they wish to bundle • Will take data, time, and benefit to get providers to sign up for Models 2 to 4 • Some health plans are bundling now – such as vaginal deliveries @Best Practice Associates 43 Typical Errors in Contract Modeling • Overall systems integration – lack of consolidated database to share payor information experiences for such as “case rates”, etc. • Chargemaster increases – tracking and tying into contract renewals due to independent Managed Care system and/or lack of communication between Finance and Managed Care/PFS • Costs of managed care portfolio – Service Line, Product Mix, etc. – Inpatient versus outpatient services – Resource utilization within Service Line – Resource utilization within Case Rate @Best Practice Associates 44 Typical Errors in Contract Modeling • Changes in payor administrative policies or procedures – – – – – – Coding policy changed that may vary by payor Bundling of CPT codes Claim edit programs Changes in claim payment time frames Changes in precertification policies Typically vary by payor • Legislative changes impacting product mix – shifting of traditional government programs into managed care models @Best Practice Associates 45 Typical Errors in Contract Modeling • Unresolved payor denials – Timeliness of receiving denials – Time and cost to review and challenge by type – Denial percentage factors into ongoing negotiations • Payor operational inefficiencies – Inability to credential/load and update physician info – Auditing process; internal and external – Underpayments, refunds and offsets • Shift in payor mix cannibalization – new payors entering market due to ACA Exchanges @Best Practice Associates 46 Patient-centered Medical Homes “A model of primary care that is patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety” According to the American College of Physicians, “the most effective way to realign payment incentives to support the PCMH model involves incorporating three different components: 1. a “bundled” monthly care coordination payment for medical professional work occurring outside of face-toface patient visits; 2. a visit-based fee-for-service component; and 3. a performance-based component to reward the provision of efficient, high-quality services” @Best Practice Associates 47 Managed Care Contracts • “Evergreens”: review cancellation/termination language and consider ending by September 30, 2014 for NEW contract under ICD-10 • Beware of amendments: payors will ‘slip’ in amendments regarding the “implementation of ICD-10” without full details of their readiness and/or changes in their systems, edits, medical necessity changes, payment protocols @Best Practice Associates 48 Language to Question! • “in preparation for the implementation of ICD-10, we will process claims as usual and accept the submitted codes. The reimbursement for the year 2014 -2015 will be budget neutral, reflecting no impact on XXXXX hospital” • Similar language but with a twist – “…although our processing protocols may have changed due to ICD-10, reimbursement will be budget neutral for 2014 – 2015” • YOUR ANALYSIS MAY SHOW DIFFERENT REIMBURSEMENT BENEFITS! @Best Practice Associates 49 Language to Add to a Contract • With the discontinuation of ICD- 9 as of September 30, 2014, the auditing of historical claims will not involve any claims with initial DOS over three (3) years old from review request date • As of October 1, 2017, no claims with ICD-9 codes will be available for audit. Any open claims with ICD-9 codes must be resolved by January 1, 2018. @Best Practice Associates 50 Language to Consider! • All new and/or modified system processing changes to the payor system must be shown to the hospital/practice and explained by the payor. This includes crosswalks, medical necessity edits, claim processing edits, etc. • As of October 1, all claims will be processed using ICD-10 codes and no crosswalks to ICD-9 will occur. @Best Practice Associates 51 HIPAAA Non-Covered Entities ICD-10 Myths and Facts “Because ICD-9-CM will no longer be maintained after ICD-10-CM/PCS is implemented, it is in noncovered entities’ best interest to use the new coding system. The increased detail in ICD-10CM/PCS is of significant value to non-covered entities. CMS will work with non-covered entities to encourage their use of ICD-10-CM/PCS” @Best Practice Associates 52 HIPAAA Non-Covered Entities The ICD-10 Transition: Focus on Non-Covered Entities Definition of “best interest” • ICD-10-CM codes will provide expanded detail in injury codes, which will help automobile insurance and workers’ compensation program coordinate payment • ICD-9-CM codes will no longer be maintained once ICD-10 has been implemented. The ICD-9-CM code set will become less useful and resources will be continually harder to obtain after three years • Not adopting to ICD-10 coding could lead to undue hardship for non-covered entities’ provider. They will have to translate from ICD-10 manually @Best Practice Associates 53 Medicaid Expansion Arizona Kentucky New Mexico Arkansas Maryland New York California Massachusetts North Dakota Colorado Michigan Ohio Connecticut Minnesota Oregon Delaware Missouri Rhode Island District of Columbia Montana Vermont Florida Nevada Washington Hawaii New Hampshire West Virginia Illinois New Jersey Kansas and South Dakota – undecided as of May 2013 @Best Practice Associates 54 Health Exchange Background State Decisions for Creating Health Exchanges Declared State-Based Exchange (16 States + D.C.) Planning for Partnership Exchange (7 States) Defaulted to Federal Exchange (27 States Source: http://kff.org/health-reform/state-indicator/healthinsurance- exchanges/#map. Dated May 28, 2013. @Best Practice Associates 55 Health Exchange Background Coverage Requirements and Tiers An exchange must offer a plan choice in each of the five categories, which are based on the actuarial value of the plan. The actuarial value is based on the average cost share of covered health expenses reimbursed by the plan for the typical population. In a given state, a participating payor must offer at least one Platinum or Gold plan. The ACA also states that the federal government will select at least two multistate carriers available in every state and every exchange. The plans must provide the 10 essential health benefit (EHB) categories in total, as defined by CMS. However, states can require a higher level of benefits. The federal subsidy is indexed on the value of the Silver tier. Gold (80%) Catastrophic (Under 30 or Qualify for Exemption) [No Subsidy Provided] For example, a Gold plan would cover the equivalent of $2,000 for an average patient’s $2,500 in annual medical expenses. Higher coverage requires higher premiums. @Best Practice Associates 56 0% to 133% of FPL Eligible for Medicaid [If State Expands Program] DSH may also be effected Description 100% to 250% of FPL Eligible for CostSharing Support. Basic Health Plan (133% to 200%) 100% 133% 150% 200% 133% to 400% of FPL Eligible for Health Exchange Subsidy [Sliding Scale Subsidy as Tax Credit] 250% 300% 400% Individual1 $11,490 $15,282 $17,235 $22,980 $28,725 $34,470 $45,960 Family of Four1 $23,550 $31,322 $35,325 $47,100 $58,875 $70,650 $94,200 Insurance Premium Cost Target Percentage of Income2 2.0% 2.0% 4.0% @Best Practice Associates 6.3% 8.1% 9.5% 9.5% 57 IV. Exchange Plan Premiums State Differences California Covered California Description Regions • 19 regions, largely along • Health Plans county lines. Rural counties were grouped together. Blue Shield of California plans are offered in all 19 regions. Kaiser is offered in 18 of 19 regions. • Between three and six • • The whole state is a single region. Maryland Maryland Health Connection • The whole state is a single • • 13 plans participating. • Anthem Blue Cross and • Coverage Vermont Vermont Health Connect plans are offered in all 19 regions. There is an average of 4.5 plans offered in any given region. Average of 12 hospitals and 2,000 physicians per region. • Two health plans will be • region. There will be six navigator regions. 13 health plans will be offered. offered. Blue Cross Blue Shield of Vermont and MVP Healthcare. • Each plan will offer two Bronze, two Silver, one Gold, and one Platinum. Vermont is building to a statewide universal health insurance coverage model. @Best Practice Associates • All plans will be offered • throughout the state. Provider networks will vary by health plan. 58 Provider Exchange Financial Impact Analyzing the impact of payor mix changes will depend on several key assumptions • Develop a current status view – revenue and profitability by payor • Project anticipated payor mix changes – How much volume will shift to the exchanges? – How much additional Medicaid? • Project anticipated reimbursement – Sensitivity analysis on the range of reimbursement possibilities – Percentage of current Medicare or commercial rates • Determine potential impact on profitability • Negotiate rates for exchange products based upon how much margin reduction can be tolerated @Best Practice Associates 59 Contract Questions • What types of contracts will your organization be offered from the payors? • What type of analysis are the payors doing regarding your clinical experience? • Do you want contracts based on their data or YOURS? • Will other contract types be offered? Next!!! @Best Practice Associates FFS • Outpatient • Physicians Case • MSDRGs Rates • Am Surg • Inpatient Per Diem • Distinct Services 60 Preferred Contract Approach • A new contract allows for the greatest flexibility to – Define clinical protocols – Negotiate rates – Limit terms (audits, take-backs, length, etc.) • Does not interfere with current contracts • Establishes strength based on payor history and the challenge to change • Your data shows profitability under new approaches! @Best Practice Associates Value based Contract ICD-10 Case Rates Bundled Services Risk/Cost based Contract 61 Summary of Next Steps! • Perform Profitability Analysis by Payor! • Identify “Evergreens” with lowest profit and determine termination requirements! • Perform an ICD-10 Financial Analysis for both inpatient and outpatient! • Review current Contract language for revision! • Openly discuss New Contract options! – – – – Value-based Purchasing Bundling with Physicians or without Physicians Risk/Cost based Contracts Other Considerations • Draft a “data-supported” White Paper! • Conduct a meeting with Finance and Managed Care! • MOVE FORWARD!!!! @Best Practice Associates 62 ???QUESTIONS??? @Best Practice Associates 63 CONTACT INFORMATION @Best Practice Associates 64