healthcare reform preppers exclusively for: aaham june 19, 2013

Healthcare Reform Preppers Exclusively for: AAHAM June 19, 2013

2 The Status of Reform Understanding Todays Enrollment Dilemma The Preppers Enrollment Survival Kit 2012 Advanced Patient Advocacy Todays Outline

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

Why did we need reform? 4 A changing population with changing healthcare needs

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/

6 Medicaid / Insurance Reform Medicaid Expansion Insurance Exchanges PPACA MANDATES

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

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.

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

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

ACA predicted to cut uninsured rate 11 Source: KFF: The Uninsured: A Primer (2012);KFF: The Uninsured: A Primer (2012)

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

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

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

How Can Providers Prepare? 17

Tools Providers Need in Their Survival Kit 18 2012 Advanced Patient Advocacy What Role? ENROLLMENT STRATEGY Streamline Update Policies & Procedures

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

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?

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?

Building an Enrollment Strategy 22 Target Broaden Maximize Take advantage of the Disability Opportunity

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

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

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

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

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

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

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

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)

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

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

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

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

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

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.

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

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

Funding Opportunities Watch for Funding Opportunities & Apply Grants.gov HHS Grants Forecast

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/

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

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

Thank You 43 Michael D. Wilmoth, Esq. [email protected] (703) 403-3521 www.aparesults.com

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

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

healthcare reform preppers exclusively for: aaham june 19, 2013

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