managed care contracting under icd-10 rob borchert, mba, crce-i – best practice associates lorrie...
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Managed Care Contracting Under ICD-10
Rob Borchert, MBA, CRCE-I – Best Practice AssociatesLorrie Borchert, CPC, CRCE-I – Best Practice Training Institute
Maryland AAHAM Education ConferenceJanuary 17, 2014Linthicum, MD
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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?
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ICD Code DifferenceCM - Clinical Modification
1 2
Series1 13000 68000
5000
15000
25000
35000
45000
55000
65000
75000
ICD 9 ICD 10
PCS- Procedure Coding System
1 2
Series1 11000 87000
5000
15000
25000
35000
45000
55000
65000
75000
85000
95000
ICD-9 ICD 10
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Mapping Between Old And New Systems
• General equivalence maps (GEMs) between ICD-9-CM 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
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Mappings
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GEMs Mapping
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CMS GEMS vs. CMS Reimbursement Mappings
Source: Deloitte Consulting presentation “Do Not Underestimate ICD-10’s Impact on Population Health Management” at the Forum 10 in Washington, DC 10/15/10
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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
9
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!!!!
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Sports MedicineHit 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
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ICD-10-PCS Code Structure
ICD-10 PCS Code Structure:
1 2 3 4 5 6 7
Section
BodySystem
RootOperation
Body Part
Approach
Device
Qualifier
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ICD-10-PCS Example
Interphalangeal fusion of right great toe, percutaneous pin fixation
OSGP34ZSection 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
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ICD-10 Impacts
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Impacts to People
Source: AAPC website
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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
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Impacts to Process
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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
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Revenue Cycle Impacts
Medium Impact to process and training Large impact to process and training
IT A
pplic
ati
ons
Clin
ical
Busi
ness
Pro
cess
/Pa
tient
Acc
ess
Payment Posting
Scheduling
Patient Access Services Charge/Coding Integrity Patient Financial Services
Pre-Registration
Financial Counseling
Charge Capture
Entry
Coding Assignment
Account Resolution
Claims Processing
Test Order“Optional
”Clinical
Doc.
Clinical Interventio
n
Scheduling
PatientAccounting
Registration
Performance Measurement
Pricing
HIS (including
CPOE) HIMClaims
Clearinghouse
Patient Accounting
Case Management
Utilization Management
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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
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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.
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ICD-10 Impact on Payor Reimbursements
Common Reimbursement Arrangements
Potential ICD-10 Impact Identified by Independent Analysis
DRGs and other case rates
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 MS-DRGs (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.
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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 ICD-10 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, pass-through 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.
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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.
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ICD-10 Impact on Payor Reimbursements
Common Reimbursement Arrangements
Potential ICD-10 Impact Identified by Independent Analysis
Other Reimbursement Arrangements
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.
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Examples of I-9 to I-10 ConversionsCrohn’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 ICD-10 PCS
Implementation or insertion of radioactive elements
261 PCS codes for Anatomical sites specified21 distinct Approaches
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MCC/CC Category ConversionConversion 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 # ICD-10 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
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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
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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
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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
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In God, We Trust, All Others Bring Good Data!
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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?
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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 serviceAssess 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
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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
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Value-Based Benefit DesignLow 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
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Value-Based Benefit DesignNo 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
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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
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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
Is This Covered?
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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
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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.
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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)
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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)
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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
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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
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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
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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
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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-to-face patient visits;
2. a visit-based fee-for-service component; and3. a performance-based component to reward the provision of
efficient, high-quality services”
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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
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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!
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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.
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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.
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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 non-covered entities’ best interest to use the new coding system. The increased detail in ICD-10-CM/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”
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HIPAAA Non-Covered EntitiesThe 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
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Medicaid ExpansionArizona 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
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Declared State-Based Exchange (16 States + D.C.)Planning for Partnership Exchange (7 States)Defaulted to Federal Exchange (27 States
Health Exchange BackgroundState Decisions for Creating Health Exchanges
Source: http://kff.org/health-reform/state-indicator/health-insurance- exchanges/#map. Dated May 28, 2013.
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Health Exchange BackgroundCoverage 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.
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Description 100% 133% 150% 200% 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% 6.3% 8.1% 9.5% 9.5%
Health Exchange Background
0% to 133% of FPLEligible for Medicaid[If State Expands Program] DSH may also be effected
100% to 250% of FPLEligible for Cost-Sharing Support.Basic Health Plan (133% to 200%)
133% to 400% of FPLEligible for Health Exchange Subsidy[Sliding Scale Subsidy as Tax Credit]
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IV. Exchange Plan Premiums State Differences
Description
California Covered California
Vermont Vermont Health Connect
Maryland Maryland Health Connection
Regions • 19 regions, largely along county lines.
• Rural counties were grouped together.
The whole state is a single region.
• The whole state is a single region.
• There will be six navigator regions.
Health Plans • 13 plans participating.
• Anthem Blue Cross and Blue Shield of California plans are offered in all 19 regions.
• Kaiser is offered in 18 of 19 regions.
• Two health plans will be offered.
• Blue Cross Blue Shield of Vermont and MVP Healthcare.
• Each plan will offer two Bronze, two Silver, one Gold, and one Platinum.
13 health plans will be offered.
Coverage • Between three and six 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.
Vermont is building to a statewide universal health insurance coverage model.
• All plans will be offered throughout the state.
• Provider networks will vary by health plan.
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Provider Exchange Financial Impact
• 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
Analyzing the impact of payor mix changes will depend on several key assumptions
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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!!!
•Outpatient•Physicians
FFS
•MSDRGs•Am Surg
Case Rate
s
•Inpatient•Distinct Services
Per Diem
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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!
Value based
Contract
ICD-10 Case Rates
Bundled Services
Risk/Cost based
Contract
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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!!!!
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???QUESTIONS???
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Lorrie Borchert – [email protected]
(540) 226 - 2034
CONTACT INFORMATION
Rob Borchert – [email protected]
(315) 345 - 5208