Payor

Marcia Brauchler, MPH, CMPE
CPC, CPC-H, CPC-I, CPHQ
March 10, 2014
10:00am -11:30am
All Rights Reserved.
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 This
is not legal advice and
represents only recommendations
and observations in general.
 We recommend you use this
information to better examine
your practices and to open a
dialog within your practice.
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HANDOUT:
GLOSSARY
Source:
http://healthreform.kaiserpermanente.org/en/glossary
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A
virtual marketplace to shop and
compare health insurance plans.
 Can still shop off the Exchange.
 Doesn’t include Medicare or Medicaid.
1: Understand how we got here, and
where we are today with the ACA
Health Insurance Exchanges
2. Analyze your Practice’s ACA Health
Insurance Exchange participation
strategy
3. Describe the impact of the ACA
Health Insurance Exchange on the
practice’s Revenue Cycle
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Patient
Protection
and
Affordable
Care Act of
2010
(PPACA)
P.L. 111148
Health Care
and
Education
Recovery
Act of 2010
P.L. 111152
Affordable
Care Act
(ACA)
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Individual
Mandate
Medicaid Expansion
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8
2010
2011
2012
2013
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20
11
14
Number of Provisions:
Resource:
http://kff.org/interactive/implementation-timeline/
Note: timeline not to scale!
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2014
2015
16
1
2016
2018
Number of Provisions:
1
1
Resource:
http://kff.org/interactive/implementation-timeline/
Note: timeline not to scale!
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

Healthcare.gov site & enrollment
deadlines.
2 contraception-mandate cases:
◦ Conestoga Wood Specialties Corp. v.
Sebelius
◦ Sebelius v. Hobby Lobby Stores, Inc.

Cancellations of millions of
individual health insurance plans.
◦ “If you like your plan, you can keep it.”
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1.
Did your state do an exchange?
2.
Did your state expand Medicaid?
3.
Did your state create a Co-Op?
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HANDOUT:
State Status
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Did your state do
Did your state
Did your state create
Name of Co-Op
an exchange?
expand Medicaid?
a Co-Op?
(default = Federal)
Federal
No
Federal
No
Federal
Yes
Yes
Meritus Health Partners
Federal
No
State
Yes
State
Yes
Yes
Colorado HealthOp
State
Yes
Yes
HealthyCT
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
10/1/2013 through 3/31/2014
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Only enrollment questions:
Age
 Geographic area
 Family composition
 Annual projected household income
 Tobacco use

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
200,062 enrolled in State and Federal exchanges
10,000,000
8,000,000
6,000,000
Expected
4,000,000
Enrolled
2,000,000
0
Exchange
Medicaid
SOURCE: http://www.commonwealthfund.org/Blog/2013/Nov/Enrollment-in
-the-Affordable-Care-Act.aspx?view=print&page=all
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Effective 2011:



Medical Loss Ratio 80% for individual
& small group market.
85% for large group & Medicare
Advantage.
OR . . . Rebates due to insured’s.
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 The
payors had to submit to the
State “division of insurance”:
◦ Benefit packages with essential benefits
◦ Provider networks
◦ Premium data
◦ Geographic areas
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HANDOUT:
State Insurance Agencies
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INDIVIDUAL:

1 with or without Family
“SHOP”:



2 – 50 or 100 people (by state)
Federal delay until 2015.
States can still operate.
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1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Ambulatory patient services
Emergency Services
Hospitalization
Maternity and newborn care
Mental Health and substance use disorders
Prescription drugs
Rehabilitative services and devices
Laboratory services
Preventative and wellness services and chronic
disease management
Pediatric services including oral and vision care
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 Basic
Plan in each state
 Limits on Cost-Sharing
◦ $6,350/individual max 2014
◦ $12,700/family max 2014
 Creates
4 categories of Plans . . .
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 “Metallic”
plans
SOURCE: http://thedailyworld.com/sites/files/article/162385_web_C-Jocks-USGym-3c.jpg
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60%
Bronze
70%
Silver
80%
Gold
90%
Platinum
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PREMIUM
COST-SHARING
Co-Payments
Co-Insurance
Annual Deductibles
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PREMIUM –
Advanced Premium Tax Credit (APTC)
Up to 400% FPL
Subsidy forwarded directly to
Insurer monthly or Deducted by
Insured on annual tax return
(Enrollee’s responsible for their
portion, if any)
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PREMIUM SUBSIDY:
Illustration Only:
Family of 4, makes $52,988 annually (225% FPL)
SILVER PLAN
MONTHLY PREMIUM
$1,250
APTC:
$933
INSURER
Family:
$267
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COST-SHARING
Up to 250% of FPL
Co-Payments
Co-Insurance
Annual Deductibles
ONLY
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Cost-Share Reduction:
Illustration Only
Family of 4, makes $52,988 annually (225% FPL)
Federal
SAMPLE
PLAN
Silver
Plan
Responsibility
Deductible
Out of Pocket
Maximum
$1,500
$750
Subsidy
$750
$6,400
$1,500
$4,900
Coinsurance
30%
30%
30%
Office Visit
Copayment
$40
$40
$40
Family
Government
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Day 1 – Day 30
Day 31 – Day 90
Day 91 +
Insurer Liable
Claims are
Pended
Claims Denied
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2. Analyze your Practice’s ACA
Health Insurance Exchange
participation strategy
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Health Insurance Exhange
Participating Status
DECISION TREE
Step 1:
Do you know the Payors offering products in your your State’s Exchange?
Source: Access the state’s exchange site or healthcare.gov.
No.
Research.
Yes
Step 2:
Do you participate with the Payor?
Source: Payor Participation Agreement.
Yes
No.
Business as usual.
Step 3:
Do you know the specific product being offered by the Payor on the Exchange?
Source: Payor website or provider relations.
No.
Research.
Yes
Step 4:
Has the Payor developed a narrower network?
Source: Contact each payor
No.
Yes
Business as usual.
Are you participating in the Product?
STEP 1: Do you know the Payors offering products in your State’s Exchange?
Payor – Individual Plans
All Savers Insurance Company (subsidiary of UnitedHealthcare)
Anthem Blue Cross and Blue Shield
Cigna
Colorado HealthOP
Denver Health
Humana
Kaiser
New Health Ventures (subsidiary of Colorado Access)
Rocky Mountain Health Plans
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STEP 1: Do you know the Payors offering products in your State’s Exchange?
Payor – Individual Plans
Silver State Exchange / Healthcare Plan of Nevada
Anthem Blue Cross and Blue Shield
Nevada Health Co-Op
St. Mary’s Health Plan
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STEP 1: Do you know the Payors offering products in your State’s Exchange?
Arizona
Meritus Health Partners
Montana
Montana Health Co-Op
Colorado
Colorado HealthOp
Nebraska
CoOportunity Health
Connecticut
HealthyCT
Nevada
Nevada Health Co-Op
Illinois
Land of Lincoln Health
New Jersey
Health Republic Insurance of NJ
Iowa
CoOportunity Health
New Mexico
New Mexico Health Connections
Kentucky Health
Cooperative, Inc.
Louisiana
Louisiana Health
Cooperative, Inc.
Maine
Maine Community
Health Options
Maryland
Evergreen Health
Cooperative
Massachusetts Minuteman Health Inc.
New York
Health Republic Insurance of NY
Ohio
InHealth Mutual
Michigan
Kentucky
Consumer Mutual
Insurance of Michigan
Oregon
Health Republic Insurance of OR;
Oregon's Health Co-Op
South Carolina Consumers' Choice Health Plan
Tennessee
Community Health Alliance
Utah
Arches Heatlh Plan
Wisconsin
Common Ground Healthcare
Cooperative
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STEP 2: Do you participate with the Payor?
 Provider
directory
 Do you want to be in or out?
 Are you actually in/out?
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STEP 2: Do you participate with the Payor?
Health Insurance Exhange Participating Status
EXAMPLE
Want to be participating, but was not actually participating
Received
letter from
Payor, stating
in unless Opt
Out
Received
Amendment
to
Participate
10/25/20
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5/29/2013
Conversation
with payor
to confirm
PAR, but
payor said
NON-PAR
9/9/2013
Amendment
signed and
returned
10/31/
2013
CounterExecuted
Amendment
Received by
Provider
Continuous
follow-up,
11/5/2013
ONGOING
Provider
STILL not
listed on
the Payor
Website
12/6/
2013
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STEP 3: Do you know the specific product being offered by the Payor
on the Exchange?
Payor
Product
All Savers Insurance
Company (subsidiary of
UnitedHealthcare)
Anthem Blue Cross and
Blue Shield
Cigna
Navigate
Humana
Kaiser
Pathway
Local Plus and Local
Plus IN
HMOx
KP Network
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STEP 3: Do you know the specific product being offered by the Payor
on the Exchange?
Alpha Prefix
Health Benefits Plan Option
VAB, XFV Individual (Exchange)
Small Group (Exchange)
Network Name
Pathway X
Enhanced
Pathway X
Enhanced
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STEP 3: Do you know the specific product being offered by the Payor
on the Exchange?
Alpha Prefix Health Benefits Plan Option Network Name
Pathway
VAB, XFV
Individual (OFF Exchange)
Enhanced
Pathway
XFI, XFS,
Small Group (OFF Exchange)
XFX, VAD
Enhanced
Pathway
VAE
Large Group (OFF Exchange)
Network
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STEP 4: Does this Payor have a narrower network?
 Is
there a Narrow Network in the
Payor’s Exchange product?
 Are you in or out?
 What other Provider Types are “IN?”
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STEP 4: Does this Payor have a narrower network?
 Blue
Shield of California: 53% of
doctors, 78% of hospitals (vs. regular
network)
 Anthem
BCBS of New Hampshire:
narrow hospital network
SOURCE: http://www.nytimes.com/2013/09/23/health/lower-healthinsurance-premiums-to-come-at-cost-of-fewerchoices.html?pagewanted=all&_r=0#
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3. Describe the impact of the ACA
Health Insurance Exchange on the
practice’s Revenue Cycle
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Step:
1
2
3
4
5
6
7
8
9
10
11
12
Billing Function
Service Expectation
Registration
Obtain Demographics & Medical Insurance Information
Eligibility & Benefit
Verification
Prior Authorization
Eligibility and benefits are verified at least 24 hours prior to visit
Determine prior authorization for required services
Time of Service Collections Collect cash co-payments and portions of anticipated patient
balances
Charge Entry
Days to Bill; Patients with charges submitted
Electronic Claim Submittal
EDI Denial/rejection rate
Account Follow-up
Days in A/R
Payment Posting
Cash posted and balanced
Denial Management
Due to timely filing limits; Overall denial rate.
Payment Variances
Reviewed every 30 days
Patient Collections
Patient Accounts Reviewed with Physicians
Management Reporting
Reports provided to physician within 10 days of Month End
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Step: Billing
Function
Registration
1
Service Expectation
Obtain Demographics & Medical Insurance
Information
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Payer / Network Participation Status
Cigna
Products
☐ Participating
☐ Commercial
☐ NOT Participating ☐ HMO Select
☐ LocalPlus
Agreement Type:
☐ Group
☐ Individual
Contracting Entity:
☐ Direct
☐ IPA
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Cigna LocalPlus
Humana HMOx
United Healthcare
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Step:
2
Billing Function
Service Expectation
Eligibility & Benefit Eligibility and benefits are verified within 48 hours prior to visit
Verification
FOR EXAMPLE:
COLORADO EXAMPLE - CRS 10-16-704(f)
(2 business days prior to services); CRS 1016-704(g) (eligibility contingent on payment
of premium (if verification requested during
grace period)
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Step: Billing
Function
Prior
Authorization
3
Service Expectation
Determine prior authorization for required services
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Step:
4


Billing
Function
Time of Service
Collections
Service Expectation
Collect cash co-payments and portions of anticipated
patient balances
Deductibles will vary.
Preventive Care: covered at 100%, but make
sure they are eligible, and know what is
considered Preventive Care.
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Step: Billing
Function
6
Electronic
Claim
Submittal
Service Expectation
EDI Denial/rejection rate
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Step: Billing
Function
Payment
Variances
10
Service Expectation
Reviewed every 30 days
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Step: Billing
Function
Patient
Collections
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Service Expectation
Patient Accounts Reviewed with Physicians
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Step:
12
Billing
Service Expectation
Function
Management Reports provided to physician within 10
days of Month End
Reporting
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



Toe in water in pool . . . Don’t jump in!
Don’t panic
Know what your exposures . . . Realistically . .
Manage it . . .
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HANDOUT:
RESOURCES
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QUESTIONS?
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Marcia Brauchler, MPH, CPC, CPHQ
Physicians’ Ally, Inc.
101 W. County Line Rd. #230
Littleton, CO 80129
(303) 586-9390
Fax: (303) 586-9393
Cell: (303) 250-3236
[email protected]
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