Population Eligibility Management For Government Healthcare Programs September 9, 2014 NAVEOS ®; Proprietary & Confidential 1 Presentation Overview o FFY 15 Final Rule o What is Population Eligibility Management? o What are the major groups? o Why is this so critically important now? o What metrics need visibility? o Predictive modeling for SSI eligibles o How do you get the necessary data? o Provider Action Items NAVEOS; Proprietary & Confidential 2 “New DSH” Calculation Step 1: Empirically Justified Amount 25% of Old DSH Step 2: DSH “Add-On” Payment Product of 3 Variables NAVEOS; Proprietary & Confidential 3 Federal DSH “Add-on” Calculation Variable 1 75% of the Federal DSH Payment calculated using the “OLD” DSH model – For all DSH Hospitals * Variable 2 1- % Change in the national uninsured * Variable 3 Sum of Allowable TXIX + SSI/MedA days Sum of all DSH TXIX-SSI/MedA Days NAVEOS; Proprietary & Confidential 4 $2B - 15.5% $12.9B $10.9B $9.6B $7.6B $3.3B $3.3B 5 Factor 2 – Variances over Time – Proposed v Final – FFY 14-15 6 Factor 2 – Newly Insured Members - Proposed v Final – FFY 1415 7 Factor 1 - Final Rule– FFY 14-15 8 Factor 1 – Proxy for Utilization for New Medicaid Members 9 Factor 1 – Utilization for New Medicaid Members – Previously Insured 10 Factor 2 – Cost of the “Assumption” Provider Action: Include calculation of Factor 1 as a protest item for FFY 14/15 and forward cost reports 11 CMS Projections 2016-2024 12 What are the key feature of Population Eligibility Management? o Episodic Continuous data flows o Delta tracking o Transition management o Presumptive Eligibility o Predictive modeling o Visibility NAVEOS; Proprietary & Confidential 13 Why is this so critical now? o Zero Sum Medicare DSH Paradigm o Medicaid Expansion o Medicaid DSH Reduction o Medicare DSH Reduction o Prospective UCP calculation o Aging of the baby boom NAVEOS; Proprietary & Confidential 14 What are the major groups we are managing? 57% of all insured in the United States Medicaid 9 Million Duals 65+ Million Other State/Local Indigent Care 30+ Million Medicare 50 Million+ 5.5M SSI 15 Why is this so critical now? SPRING CLEANING: IL Medicaid is running a member rolls clean-up project, reviewing more than 60,000 members a month. So far about half of those reviewed are getting the boot. Agency officials say about 33% of those are back on Medicaid quickly, after providing the required documentation. What happened to the other 67% of 50% or 33% who did not get back on? NAVEOS; Proprietary & Confidential 16 What metrics need visibility? o Eligibility Loss o Eligibility Downgrade o Primary Secondary Transition o Presumptive Status o Queue Mgmt NAVEOS; Proprietary & Confidential 17 18 19 300 IP days/1000 covered lives 270 days * $940/day = $254K 20 Where/how do we get this data? 21 LDS MedPar File Standard Medicare Fraction Adjustment NAVEOS; Proprietary & Confidential 22 Damages Calculation & Package Data Sources – LDS MedPar Files – 2006-2011 LDS MedPar files CAN BIC 1. Critical File – Submit DUA ADMIT 2. 2006-2011 available now DISCH 3. MA Flag – admit specific & based on shadow bill 4. Only CMS Sourced SSI Days value Provider ID Provider SPU Code LOS Pre-ruling SSI Days Covered Days 5. Good starting point for damages Not comprehensive Not 100% accurate MA Status Post-ruling SSI Days Federal Fiscal Year MedPar Version NAVEOS; Proprietary & Confidential 23 Medicare -EDI 24 Medicare –EDI – Part A/B Eligibility 25 Medicare –EDI – Medicare Advantage info 26 Data Sources/Flow & Regulatory Logic Filter Title XVIII Eligibility & Benefit data – HETS 270/271 – CWF- Title XVI (SSI) Clinical Disability Criteria State Specific Title XIX Benefit/Coverage Rules OOS Title XIX Adjudicated & Paid Claims Data PSR IN-STATE TXIX Elig & Benefits; Third Party Liability Data NAVEOS; Proprietary & Confidential One Way Data Transfer QUARTERLYr Provider Demographic , Payer, OP Clinical, RevCode, CDM, NDC MONTHLY VENDOR/ HOSPITAL Title XVIII Benefit/Coverage Rules LDS MedPar Files Medicare HCRIS & PSF File 27 Why are “Eligible” Medicaid Members so valuable? Medicaid Losses on WS10 Non Covered Services for UCC Medicaid EHR Payment $825/Day $50/Day State DSH reimbursement 3rd Party Payer Payment $500/Day Empirically Justified Amt-FDSH $70/Day UCP Portion of Federal DSH $205/Day 28 SCHIP Member Conversion to Title XIX Enrollment OP Hosp TXIX 17 -SCHIP EPIC TXIX May 15 During an Outpatient visit an SCHIP member receives a pregnancy diagnosis June 30 Data flows through VENDOR rules for pregnancy – generates notice to 3rd party and includes in monthly report for client hospital Hospital Social Worker or 3rd Party Vendor reaches out to Patient and guides her through Medicaid enrollment NAVEOS; Proprietary & Confidential PreAdmit Delivery Mom PPPE NB Derived Eligibility August 1 VENDOR verifies SCHIP member is successfully enrolled in Medicaid 29 Preventing Gaps in Medicaid Coverage Address Changed Noted National Medicaid“Churn” rate for 2012 = 19% Medicaid Member moves – no forwarding address MAIL returned – Undeliverable as Addressed Medicaid MMIS Membership terminated NAVEOS; Proprietary & Confidential Denied – No coverage at date of service Eligibility/Payment-DSH Federal & State 30 31 Medicare/SSI Eligibility Management 32 Why SSI Ratio Management? SSIMM 340B 75% EJA-6B SSI Redetermine NAVEOS ®; Proprietary & Confidential SSI Retro Appeal 33 Predictive Modeling for SSI eligibles Identifying Enrolling Predicting NAVEOS; Proprietary & Confidential Confirming Tracking 34 SSI Member Management - Identify LDS MedPar File TXIX Eligibility SDX File Identify SSA-3288 Medicare Eligibility Database NAVEOS; Proprietary & Confidential 35 36 SSI Member Management - Confirm Confirm SSA-3288 HETS/FISS 270/271 NAVEOS; Proprietary & Confidential 37 SSI Member Management – Track & Report LDS MedPar File TXIX Eligibility SDX File EDI SSI Lost New SSI Pending SSI MDSS Not MedPar Track & Report HETS/FISS 270/271 NAVEOS; Proprietary & Confidential SSIMM Reporting Hospital Decision Support 38 SSI Member Management - Predict MDSS SSIMM DXPX NDC db LDS MedPar File Predictive Model – DXPX-NDC Predict SSI Disability Clinical criteria DUAL-ELIGIBLE TXIX Eligibility SDX File NAVEOS; Proprietary & Confidential 39 SSI Member Management - Enroll 3rd Party Title XVI Firm Internal Resource Enroll NAVEOS; Proprietary & Confidential 40 Provider Action Items: Managing Eligibility 1. Develop/use/outsource the ability to pro-actively manage the eligibility of your Medicare/ Medicaid/SCHIP/OSLICP members to ensure that these metrics are the highest supportable value for Federal & State DSH and UCC. 2. If you have already filed your 2013 cost reports with a “placeholder” DSH value, update as soon as possible to the most accurate and current value available. Get the updated and supportable 2013 values from your cost report into the HCRIS db NLT Dec. 2014. 3. Institute periodic (no less often than quarterly) reviews of FFY 2013 and forward DSH Logs AND Uncompensated Care metrics for Charity Care and Non-Medicare Bad Debt – If appropriate file amended cost report. 4. For 340B providers - Implement SSI Ratio Management strategies to identify and manage, and report the eligibility for this key population subset – That algorithm has not changed & OLD DSH = 40-50% of 2013 Empirically justified amount by FFY 2019 5. If you do not already have your LDS MedPar files for 2004-2011, order them immediately to ensure that you know what Medicare thinks is Medicare Advantage and to identify your SSI members. 41 NAVEOS; Proprietary & Confidential 6. Include calculation of Factor 1 as a protest item for FFY 14/15 and forward cost reports – lower utilization of “new” Medicaid members is unsupported by empirical data 42 QUESTIONS? Contact Information 1-888-550-2708 www.NaveosData.com Robert Gricius Chairman & CEO 703-444-2422 NAVEOS; Proprietary & Confidential Charlene Mathis Regional Director of Sales (571) 455-5336 [email protected] 43
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