Healthcare Reform Preppers Exclusively for: AAHAM June 19,
2013
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2 The Status of Reform Understanding Todays Enrollment Dilemma
The Preppers Enrollment Survival Kit 2012 Advanced Patient Advocacy
Todays Outline
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3 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
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Why did we need reform? 4 A changing population with changing
healthcare needs
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Congressional Goals with the new Healthcare Law 5 For a more
detailed version of this chart outlining major ACA provisions, see
APHAs Affordable Care Act Overview, available at
http://www.apha.org/advocacy/Health+Reform/ACAbasics/.http://www.apha.org/advocacy/Health+Reform/ACAbasics/
Insurance Reform 7 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) 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) Carriers
MAY NOT : Carriers MUST: More information: Healthcare.gov: Rights
and ProtectionsHealthcare.gov: Rights and Protections
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Medicaid Key Elements (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) 8 2012 Advanced Patient Advocacy Medicaid
Expansion More people are covered Expand Federal Match (FMAP) to
help states finance coverage expansion.
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Medicaid Expansion 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.effectively 138 percent
FPL 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.table
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." 9 Sources:
Kaiser Family Foundation
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Filing the Gap with the Insurance Exchange 10 Premium and Cost
Sharing Limits for Individuals up to 400% of Poverty Under Health
Reform 2012 Advanced Patient Advocacy
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ACA predicted to cut uninsured rate 11 Source: KFF: The
Uninsured: A Primer (2012);KFF: The Uninsured: A Primer (2012)
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12 Sources: KFF: The Uninsured: A Primer (2012); Advisory Board
Company: Where the States StandKFF: The Uninsured: A Primer
(2012)Advisory Board Company: Where the States Stand Red = not
expanding
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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 15 GUIDES
ADVOCATES COUNSELORS PRODUCERS
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Here is the Dilemma 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 16 2012 Advanced Patient Advocacy
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How Can Providers Prepare? 17
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Tools Providers Need in Their Survival Kit 18 2012 Advanced
Patient Advocacy What Role? ENROLLMENT STRATEGY Streamline Update
Policies & Procedures
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Understand your States 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? Update Policies & Procedures 2012 Advanced
Patient Advocacy
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Registration tools 20 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 21 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 22 Target Broaden Maximize Take
advantage of the Disability Opportunity
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Segment & Target Population(s) 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 23 2012 Advanced Patient Advocacy
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Not All Uninsured Patients are Created Equal Categorical
Patient Mix Inpatient Outpatient/ED 2012 Advanced Patient Advocacy
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
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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 Point-of-Service Modeling 2012
Advanced Patient Advocacy
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How far will you go? 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
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Are You Getting the Maximum Return on Your Enrollment Solution
Investment? 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
Supplemental Security Income COBRA Pre-existing condition coverage
New Minor & Adult groups for Medicaid Total Charges Resolved by
Payer Payments resulting from enrollment by Payer 2012 Advanced
Patient Advocacy Veterans Benefits Indian Health SCHIP Immigrant
programs Liability (MVA & WC) Insurance Exchange
Opportunities
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Connect to the right Payer Expand Screening and Enrollment More
than just Medicaid SSI is not enough Extended benefit opportunities
(COBRA, ERRP) 64 Fed. Reg. 5160, 5170 Pre-existing and high-risk
coverage Liability and Workers Compensation 28 2012 Advanced
Patient Advocacy
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Case Study: Maximized Reimbursement Originally classified as
Medicare: Six-year-old girl falls on grandmothers property
Ambulance visit to local ED Injuries comprised of joint pain
(shoulder, hip, lower extremities); contusions Case reclassified as
liability: Interview with grandmother showed active claim opened
with her homeowners policy APA negotiated with adjuster $5k
available MedPay provision APA advised refund Medicaid 29
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Go Broader Strategy: Assist patients 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)
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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: Use trending Data scrubs Registration
Staff Training 31
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One out of every ten (12.6%) working age Americans(ages 21-64)
has a DISABILITY 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 Disabled Patient Utilization 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 2012 Advanced Patient
Advocacy
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Impact of Focused Disability Enrollment a Program 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. 33 2012 Advanced Patient
Advocacy
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The Disability Opportunity 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 Accelerate disability process Maximize
Disproportionate Share reimbursement 2012 Advanced Patient
Advocacy
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Streamline Processes (eliminate redundancies) Within in your
enrollment process Between the facility and the state/county With
the patient and your process 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 35
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Its Decision Time What role will your hospital play?
(officially or unofficially) 36 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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Choosing the Provider Role 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.Become
the patients resource for all enrollment avenues 37 2012 Advanced
Patient Advocacy
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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. 38
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/http://www.cdc.gov/communitytransformation/
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Still So Much We Dont Know 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? 41 2012 Advanced Patient Advocacy
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The Moral of the Story! 42 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 2012 Advanced Patient
Advocacy
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Thank You 43 Michael D. Wilmoth, Esq. [email protected] (703)
403-3521 www.aparesults.com
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44 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.cfmhttp://kff.org/healthreform/8194.cfm
P.. F. Short, K. Swartz, N. Uberoi et al., Realizing Health Reforms
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
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
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
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.http://www.ofr.gov/OFRUpload/OFRData/2011-20756_PI.pdf
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More Important Resources 45 apha.org/advocacy/reports
apha.org/advocacy/reports Healthcare.gov (U.S. Dept. of Health and
Human Services) Healthcare.gov State Refor(u)m (National Academy
for State Health Policy) State Refor(u)m Health Reform Source
(Kaiser Family Foundation) Health Reform Source Health reform
summaryHealth reform summary; Implementation timeline; ACA federal
funds tracker; Statehealthfacts.orgImplementation timelineACA
federal funds tracker Statehealthfacts.org Health Reform Central
(Families USA) Health Reform Central Health Insurance 101
(Community Catalyst and Georgetown University) Health Insurance 101
Enroll America Enroll America Center for Medicare and Medicaid
Innovation Center for Medicare and Medicaid Innovation Federal
Register: Health Care Reform Federal Register: Health Care
Reform