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PRIVATE PAYOR OUTLOOK - APMA Laura_Thursday PM_Keys for Practice... · request for information in...
Transcript of PRIVATE PAYOR OUTLOOK - APMA Laura_Thursday PM_Keys for Practice... · request for information in...
Insurance Coverage by
Source (2015)
Employer Group – 49%
Non-group (individual and association) – 7%
Medicaid – 20% (includes dual eligibles)
Medicare – 14% (excludes dual eligibles)
Other Public – 2% (Includes military and veterans)
Uninsured – 9%
Marketplace Stability
Congressional Budget Office determined that the
individual market is currently stable due to
subsidies.
According to ASPE individual buying through exchange has an average of 30 plan choices.
CBO determined that the individual market would
also be stable under AHCA because of shifts in
insured and rearranged tax credits.
Employer group market remains stable.
April 4, 2017 ACA
Rulemaking
Shortens the annual open enrollment period for 2018 to align with Medicare and the private market. The next open enrollment period will start on November 1, 2017, and run through December 15, 2017, encouraging individuals to
enroll in coverage prior to the beginning of the year.
Requires individuals to submit supporting documentation for special enrollment periods and ensures that only those who are eligible are able to enroll.
Allows issuers to require individuals to pay back past due
premiums before enrolling into a plan with the same issuer. This is intended to address gaming and encourage individuals to maintain continuous coverage.
April 4, 2017 ACA
Rulemaking
Allows issuers additional actuarial value flexibility to
develop more choices with lower premium options for
consumers, and to continue offering existing plans. The
current nominal actuarial values are 90%, 80%, 70%, and
60% for platinum, gold, silver, and bronze, respectively, and
plans are currently allowed to deviate from these nominal
values by a de minimis range of ±2%. The rule would allow
plans to deviate below the nominal AV by 4% or above the
nominal AV by 2%.
Eliminates duplicative review of network adequacy by the
federal government. The rule returns oversight of network
adequacy to states that are best positioned to evaluate
network adequacy.
Private Market Trends
Continuing trend to provider consolidation.
Big health systems accept risk; determine how to
incentivize pay providers.
Physician Payment by
Private Health Plans
Continuing to adopt value-based payment
mechanisms.
Seeing it increasingly funded by MLR savings and
paid out based on quality. Primary Care remains
the focus, with certain exceptions for inpatient
facilities.
One study shows that in 2011 46% of payment
arrangements had a value based feature – expected to increase to 75% by 2017.
Medicare Advantage plans are contracting with “ACOs.”
Other Marketplace
Innovations
Movement around rewards and incentives for
insured individuals.
In some case requires significant health care
data.
Medicare Advantage
Market Snapshot In 2016, 31% of beneficiaries enrolled in MA plans.
2,034 Medicare Advantage plans are available nationwide for individual enrollment in 2017 (relatively stable since 2011). HMOs represent 2/3s of these plans.
238 plans exited the market in 2016 – mainly low enrollment plans.
271 plans were offered for the first time in 2017.
Half of the 271 new Medicare Advantage plans in 2017 are offered by UnitedHealthcare, Aetna, and BlueCross BlueShield plans.
UnitedHealthcare alone accounts for about one-quarter of all new Medicare Advantage plans.
Aetna and Humana together account for another one-quarter of new plans.
New organizations offered plans in nine states: California, Illinois, Iowa, Georgia, Florida, Mississippi, North Dakota, Pennsylvania, and South Carolina.
Medicare Advantage
Market Snapshot
In 2016, 7 organizations and their affiliates
accounted for almost three-quarters of all
enrollment: UnitedHealthcare, Humana, Blue
Cross and Blue Shield (BCBS) affiliated companies (including Anthem BCBS plans), Kaiser
Permanente, Aetna, Cigna, and Wellcare.
These companies and affiliates account for 64
percent of the plans being offered in 2017.
United Healthcare and Humana are the biggest
player by far. (39% of total MA enrollment in 2016)
Medicare Advantage
CMS to offer plans “more flexibility.” Issued
request for information in most recent Call Letter.
Key enforcement and scrutiny area has been
network adequacy.
CMS has specifically asked whether there should
be different network adequacy standards for
SNPs.
Medicare Advantage
Provider Payment
Contracted Providers: Paid in accordance with their contract. CMS will generally not get involved in coverage disputes between contracted providers and MAOs. MAOs are not obligated to recognize the same modifiers or otherwise pay in the same manner as FFS if their contract allows it.
Such disputes, however, may be resolved in state courts.
Contracted Providers: Must be paid the same amounts they would have received under FFS Medicare.
Certain exceptions for some deemed providers.
Medicare Advantage
Provider Payment
Contracting Provider Payment is only regulated
by Physician Incentive Payment (PIP) rules:
Physicians/Physician groups may not be put at
“substantial financial risk” for services they do not
personally provide (referral services). Exception for
patient panel size >25,000.
Example: A podiatrist could receive full capitation
(100% risk) for services the podiatrist or podiatrist
group furnishes.
Example 2: A PCP could NOT be eligible for a
bonus payment over 33 percent of potential
payments minus the bonus if it is based on utilization
of hospitals and specialists.
Medicare Advantage
Coverage rules MA plans must cover all services covered under Medicare
FFS plus any supplemental benefits they file in their bid.
MA plans must generally follow the LCD for the place in which the service was provided and all NCDs.
Exception: MA plans that include multiple local coverage policy areas in their service area may adopt a uniform coverage policy, under which the MAO applies to plan enrollees in all areas uniformly the coverage policy that is the most beneficial to MA enrollees.
Uniform Local coverage policies must be approved by CMS and information on the selected local coverage policy must be made readily available, including through the Internet, to enrollees and health care providers.
Medicare Advantage
Coverage rules
Plans can put into place utilization requirements
not used under Medicare FFS, such as an
obligation to show medical necessity or prior
authorization requirements.
What does “covered” mean?
Does not mean provider must be paid as under FFS.
Does not necessarily mean provider must be paid
separately for the service.
Means that the beneficiary may obtain the service
for the cost sharing amount set forth in the Evidence
of Coverage.
Medicare Advantage
appeals rules
Contracted providers: Use plan’s internal appeals process. Plans free to develop process. Not regulated. Processes vary greatly.
Non-contracted providers: Must sign a waiver of beneficiary liability in order to appeal.
Ist level appeal is to plan. However, if plan affirms its decision in whole or part, it is forwarded to an independent CMS contractor (Maximus) without further action by the provider.
2nd level appeal to Administrative Law Judge available (must meet amount in controversy threshold).
3rd level appeal to MAC
Medicare Advantage
appeals rules
Non-contract Provider Payment Disputes: Where
the issue is solely whether the provider received
the amount of payment due under Medicare FFS
due to:
Miscalculation
Downcoding
Never includes medical necessity issues.
Plan internal appeals process would apply.
Special Needs Plans
Opportunities?
I-SNP, C-SNP
Model of Care
More small, locally based plans (exception, Care
Improvement Plus, owned by United).
Sometimes provider-based (particularly I-SNPs).
New MA Demonstration - Value
Based Insurance Design
Starts January 1, 2017 and runs 5 years
7 test states available for the demo in 2017 were:
Arizona, Indiana, Iowa, Massachusetts, Oregon,
Pennsylvania, and Tennessee.
11 plans in 4 states (CT, PA, IN, MA) applied and
were accepted for 2017
For 2018, plans in Alabama, Michigan and Texas
can participate
2017 plans
Indiana University Health Plans
Highmark Choice Company Pittsburgh, PA
Tufts Associated HMO Watertown, MA
Aetna Health Inc. Hartford, CT
Geisinger Health Plan Danville, PA
UPMC Health Network, Inc. Pittsburgh, PA
Keystone Health Plan East, Inc. Philadelphia, PA
Fallon Community Health Plan Worcester, MA
Healthassurance Hartford, CT
BCBS of Massachusetts HMO Blue
Value Based Insurance
Design
Creates an exception to the uniformity of benefits rule.
Allows for varied plan benefit design for enrollees with the following conditions diabetes, COPD, CHF, Past Stroke, hypertension, coronary artery disease, or mood disorders
Changes to benefit design made may include reduced cost-sharing and/or offering additional services to targeted enrollees.
Reduced Cost Sharing for High-Value Services; Reduced Cost Sharing for High-Value Providers; Reduced Cost Sharing for Enrollees Participating in Disease Management or Related Programs; Coverage of Additional Supplemental Benefits
Fox-Quamme, Hess, Redfield, Chapman, and Clark, v.
Health Net Health Plan Of Oregon, Inc., and American
Specialty Health Group, Inc.
July 7, 2015 – the first lawsuit citing Section 2706 of
the ACA was filed.
Oregon Association of Naturopathic Physicians
(OANP) participated in filing a class action suit in
federal court against the Health Net Health Plan of
Oregon and its contracted benefits provider
American Specialty Health (ASH), alleging “unlawful
and discriminatory practices.”
As initially filed Plaintiffs were 2 naturopathic
doctors and 3 patients. OANP was not a named party.
Fox-Quamme, Hess, Redfield, Chapman, and
Clark, v. Health Net Health Plan Of Oregon, Inc.,
and American Specialty Health Group, Inc.
The discriminatory Health Net/ASH practices cited in the lawsuit include:
an annual limit on the number of reimbursable visits to naturopathic physician;
the requirement of a Medical Necessity Review form, that other providers are not required to provide;
a $1,500 maximum reimbursable cap for the use of naturopathic medical services;
a limitation on certain types of medical care performed by naturopathic physicians that are within their scope of practice including, but not limited to, the delivery of preventative services; and,
reimbursing naturopathic doctors at up to 80% less than other providers for the same service rather than varying reimbursement rates based on objective quality or performance measures.
Fox-Quamme, Hess, Redfield, Chapman, and
Clark, v. Health Net Health Plan Of Oregon, Inc.,
and American Specialty Health Group, Inc.
THREE CLAIMS FOR RELIEF –
(1) Defendants actions resulted in reduced benefits to Plaintiffs and members of the Class, including denied services and reduced access to care. Patient plaintiffs and the class are entitled to recover benefits owed, to enforce their rights under the Plans, and to clarify rights to future benefits. They are also entitled to attorney fees.
(2) Defendants retained funds that should have been reimbursed to NDs, and, in some cases, to the patient plaintiffs and Class. Defendants have also profited from reduced access to medical care caused by their discriminatory practices. Patient plaintiffs and the class are entitled to equitable relief, including an injunction prohibiting Defendant from discriminating against NDs with respect to participation under the Plans or coverage of services provided under the Plans, and attorney fees.
Fox-Quamme, Hess, Redfield, Chapman, and
Clark, v. Health Net Health Plan Of Oregon, Inc.,
and American Specialty Health Group, Inc.
(3) Plaintiffs seek a declaration by this Court that
Defendants cannot discriminate against NDs with
respect to participation under the Plans or
coverage of services provided under the Plans.
Fox-Quamme, Hess, Redfield, Chapman, and
Clark, v. Health Net Health Plan Of Oregon, Inc., and American Specialty Health Group, Inc.
The class action sought several remedies, including:
(1) reimbursement to individuals who have been
denied benefits under their Health Net health
insurance plans;
(2) repayment of profits retained by Health Net as a
result of its discriminatory practices;
(3) enforcement of non-discriminatory practices in
the future; and, a court order for Health Net and ASH
that clarifies which of their practices are unlawfully
discriminatory.
Fox-Quamme, Hess, Redfield, Chapman, and
Clark, v. Health Net Health Plan Of Oregon, Inc.,
and American Specialty Health Group, Inc.
HealthNet filed a motion to dismiss
Motion was partially granted. Judge dismissed the
first complaint without prejudice and directed
OANP to file an amended complaint.
OANP filed an amended complaint.
Judge dismissed the third claim stating that only
patients harmed (not providers) can seek redress
under ERISA.
In April, case was dismissed. Merits were never
considered. Patient plaintiff could not show enough harm to have standing.
Fox-Quamme, Hess, Redfield, Chapman, and
Clark, v. Health Net Health Plan Of Oregon, Inc.,
and American Specialty Health Group, Inc.
To mitigate damages, Plaintiff agreed not to
appeal the dismissal.
Lessons learned:
Case must be brought under ERISA
Physicians don’t have standing under ERISA
Finding the right patients is the hurdle. Must be able
to show damages.
No way to address pay disparity through patients.
Dominion Pathology
Labs v. Anthem Dominion Pathology Labs., P.C. v. Anthem Health Plans of Va., Inc.
Plaintiff is three-physician practice that provides biopsy diagnostic services. Anthem unilaterally cut payment for services by 60%. Physicians negotiated with Anthem and entered an agreement, but also sued.
They bring the section 2706 anti-discrimination claims as a breach of contract claim. Both parties and the Court have agreed there is no private right of action under section 2706.
It was removed from Federal Court to State Court with a determination that there was no significant question of Federal law.
Court recently denied a motion to dismiss, but upheld Anthem’s right to terminate its contract with the group.