Navigating the Waters of Health Care Reform and Keeping your Health Care Plan Afloat Jim Williams,...
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Transcript of Navigating the Waters of Health Care Reform and Keeping your Health Care Plan Afloat Jim Williams,...
Navigating the Waters of Health Care Reform and
Keeping your Health Care Plan Afloat
Jim Williams, Benefit Specialist
Health Plan
Provider Fraud & Abuse
Health Plan Pressures
30% of all medical bills contain errors-Stephen Parente, professor of health finance at the University of Minnesota
Fraud & Abuse
Fraud & Abuse
Fraud & Abuse
Fraud & Abuse
Fraud & Abuse
Fraud & Abuse
Health Plan
Provider Fraud & Abuse
Escalating Costs
Health Plan Pressures
Escalating Costs
Escalating Costs
Escalating Costs
Health Plan
Provider Fraud & Abuse
Escalating Costs
Technological
Advancements
Technological Advancements
Specialized Radiology
Genetic Testing
Robotics
Health Plan
Provider Fraud & Abuse
Escalating Costs
Technological
Advancements
Rx Costs & Advancemen
ts
Rx Costs
In 1990, as a percentage of the total plan cost-10%
In 2011, as a percentage of the total plan cost, this has grown to 25%
Rx Costs
Contributors to Rx Costs
Double Digit InflationSpecialty MedicationsSole Source Brand Name MedicationsDirect Patient Marketing
• Consumer Choice = Less Cost Effective Choices
• Physician Over Prescribing
Health Plan
Provider Fraud & Abuse
Escalating Costs
Technological
Advancements
Rx Costs & Advancemen
ts
Over Charging & Unbundling
Bundled vs. Unbundled Dialysis Claim Comparison
Account # Patient Name AWACDialysis Facility Client ARP11/16/10-11/20/10 Item Charge Units Rate Rate Variance
90999 Hemodialysis treatment$5,820.00 3 $5,820.00 $1,001.17 $4,818.83 H6J 1270 Hectorol $1,168.00 12 $1,168.00 $51.69 $1,116.31 1J 1644 Heparin $0.00 24 $0.00 $0.00 $0.00 H6J 1756 Venofer $785.00 100 $785.00 $237.36 $547.64 H6Q4081 Epogen $2,804.25 319 $2,804.25 $436.00 $2,368.25 2A4657 Administration of drug$1,023.75 19 $1,023.75 $0.00 $1,023.75 H6
Total $11,601.00 $11,601.00 $1,726.22 ($9,874.78)
(1) Medical documentaion does not support 6 mcgs of Hectorol.
H6 - AWAC Recommended Price*Note: Please pay to the provider the allowable in the column with the dark box.
Out of Network Claim. Provider would not negotiate. AWAC recommended using ARP (R&C) pricing.Appropriate billing allowed AWAC to review/recommend coding and billing adjustments as well asmedications that did not meet medical appropriateness.
(2) According to national guidelines recommendations and prescribing information for this drug, dosing of 40,200 units of Epogen, does not meet dosing and administration guidelines per package insert.
Original Bundled Charges
AWAC Savings
Health Plan
Provider Fraud & Abuse
Escalating Costs
Technological
Advancements
Rx Costs & Advancemen
ts
Over Charging & Unbundling
Treatment Protocol Changes
Treatment Protocol Changes
Off-Label Use of Medication
Physician Dispensing
Health Plan
Provider Fraud & Abuse
Escalating Costs
Technological
Advancements
Rx Costs & Advancemen
ts
Over Charging & Unbundling
Treatment Protocol Changes
Participant Expectations
100% Coverage 100% Employer
PaidNo Out of Pocket
ExpensesUtilize any
Physician, Hospital, or Clinic
No Pre-Existing Condition Exclusions
Enrollment Upon Demand
Participant Expectations
Health Plan
Provider Fraud & Abuse
Escalating Costs
Technological
Advancements
Rx Costs & Advancemen
ts
Over Charging & Unbundling
Treatment Protocol Changes
Participant Expectations
PPACA
No Pre-Existing Under Age 19 Children Covered Until Age 26 Elimination of Lifetime Cap Elimination of Annual Cap Out of Pocket Expense Cost Sharing Deductible Cost Sharing Premium Cost Sharing
PPACA
Keeping Your Health Plan Afloat
Wellness Pre-
Certification/Case Management
Disease Management
Claims Administration
Rx Management
Reporting
Communication
data
data
Health Risk AssessmentBiometric ScreeningEducation-Goal DrivenRewards• Results• Participation ROI- $1 of Investment = $3 of Return Over 3
Years
Wellness
Early Notification Collection of Relevant Information Alert Plan to Issues (off label use) Initiation of Case Management Case Managers
• Professional Accreditation• Effective Communication w/Plan,
Participants, & Providers • Aggressive Management & Negotiation
Pre-CertificationCase Management
Patient Focused Physician Driven At the front of the Health Care
Continuum Frequent & Direct Communication
w/Plan, Participants, & Providers Examples: Cancer, Heart Disease,
Diabetes, etc.
Disease Management
Patient Focused Effective Use of Technology
• Enhances Access to Information for Patients, Providers, & Plan
Low Error Rate Prompt Turnaround Captures All Claims Data Interfaces with all segments of Plan
Claims Administration
Specialty Drugs• Rx Plan• Health Plan• Combination
Mail Order Forcing Generics w/MAC Pricing Properly & Precisely Defined AWP Personal Communications of Plan Design
to Participants Assist Individual Participants w/ Prescription
Choicesincluding Physician Communication
Data…Data…Data
Rx Management
Reporting
“ If you don’t know how you are spending your Health Care dollars, you CANNOT properly and effectively manage and contain your costs. ” “ He who controls the data controls the plan. ”
“ A well designed plan that is not properly utilized by the participants will not operate efficiently and economically for anyone. ”
Participants must understand the plan and how to use it
Must be often and consistent Must include participants and providers 60 day prior notice of changes
Communication
Summary
Whether you are fully insured or self-funded, you should have these components as a part of your Health Plan.
Self funding allows the Plan Sponsor more flexibility in the design of benefits and selection of management tools.
Be Aggressive-Make your Benefits Consultant ,TPA or Agent, work for their pay.
Health Care Reform, PPACA or by whatever name you know it by, is only a threat to the operation of your Health Plan if you allow it.
Your Benefit Consultant, TPA, or Agent does not have all the answers, however, together with an involved and informed Plan Sponsor, you can maintain a cost effective Health Plan that provides quality benefits to its participants.
P.O. Box 1688Pascagoula, MS 39568-1688
(228) 762-2500 Phone(800) 530-7222 Toll Free
(228) 769-0401 Fax