Reimbursement comlexities in an evolving marketplace · 2018-05-24 · transforming its business...

REIMBURSEMENT COMPLEXITIES IN AN EVOLVING MARKETPLACE

MAE REGALADO SENIOR CONSULTANT

DAVID GILES SENIOR CONSULTANT

Copyright © 2015, Gorman Health Group, LLC

Government Programs Leading enterprise of national consulting services and software solutions for payers and providers.

Our Mission

Our mission, as the industry’s most active professional services consultancy and provider of technology-based solutions, is to empower health plans and providers to deliver higher quality care to beneficiaries at lower costs, while serving as valued, trusted partners to government health agencies.

Washington, DC

Headquartered in Washington, DC with more than 200 staff and contractors nationwide with over 2,000 combined years of Government Programs experience.

Leadership

Deep payer and provider knowledge coupled with Centers for Medicare & Medicaid Services (CMS) regulatory expertise.

Privately Owned

Founded in 1996

Gorman Health Group is the leading solutions and consulting firm for government-sponsored health programs.

WHO IS GORMAN HEALTH GROUP?

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Our clients have one-stop access to expert advice, guidance, and support, in every strategic and operational area for government-sponsored programs, across seven verticals.

CLINICAL Changing how you approach Medical Management, Quality and Stars

PROVIDER INNOVATIONS Supporting network design and medical cost control implementation

OPERATIONS Bringing excellence to every aspect of your implementation from enrollment to claims payment

COMPLIANCE Offering guidance and support in every strategic and operational area to ensure alignment with CMS

PHARMACY Leading experts in Part D, PBM, formulary and pharmacy programs

HEALTHCARE ANALYTICS & RISK ADJUSTMENT SOLUTIONS Implementing cross-functional risk adjustment programs for medical trend management and quality improvement

STRATEGY & GROWTH Leading experts in Marketing, Sales and Strategy development that create short and long-term profitable growth

BROAD SERVICES

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Dedicated to assisting Medicaid Managed Care Organizations achieve strategic, operational and quality goals across five verticals.

CLINICAL Blending medical and pharmacy to improve care coordination, outreach and utilization management to meet the complex needs of your membership.

STRATEGIC POSITIONING Analyzing and evaluating organizational adaptability, and readiness for change in new policy and population management environments.

QUALITY PROGRAM OVERSIGHT Guidance and support to achieve the results your members and regulators expect while attaining compliance with State and Federal rules.

FINANCIAL ALIGNMENT Providing health economic solutions for the needs of the Medicaid population including long-term care, behavioral health, and chronic condition management.

OPERATIONS Creative solutions to maximize cost effectiveness, and deliver lasting results from eligibility to provider contract management, and claims.

MEDICAID SERVICES

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• Overview o Office of the Inspector General (OIG) Direction o Reimbursement under Medicare/Medicaid Duals o Claims Adjudication and Encounter Data Processing o Claims Leakage and the Path to Avoidance o Quality Control and Fraud, Waste & Abuse (FWA) Analysis o System Configuration and Framework o Medical Loss Ratio (MLR): Impact of Provider Incentives on Minimum

Requirements o Access to Care: Monitoring Network Adequacy and Provider Availability

• Performance Metrics • Promoting Business Alignment • Q&A

AGENDA

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• Today’s marketplace is constantly transforming its business models to accommodate new markets and lines of business.

• Medicaid expansion, Dual Eligibles, and the Exchanges provide an opportunity for immediate membership growth resulting in operational performance and financial strains.

• Increased membership flux often means a high volume of claims payment issues, therefore requiring a heightened awareness for payers to focus on a proactive proper payment approach that directly aligns with OIG priorities.

WHERE ARE WE TODAY?

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THERE ARE MANY MOVING PARTS

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Office of the Inspector General (OIG) Direction


2015 PROPER PAYMENT STRATEGIES

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Reimbursement

and Contract Strategy

Monitoring Downstream

Contracts

Claims Processing and

Payment Audit and FWA Analysis

System Configuration

Provider Incentives Penalties on MLR

Reporting


• Implementing and Managing a Program that Enhances Care and Controls Costs for the Dual Eligibles Population

• Forum on Strategies to Achieve Savings • Manage Long-Term Care, Implement Viable Integration Strategies,

and More!

REIMBURSEMENT UNDER MEDICARE/MEDICAID DUALS

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Copyright © 2015, Gorman Health Group, LLC 10

MEDICARE AND MEDICAID TODAY

MEDICARE MEDICAID

• Doctors • Hospitals • Prescription Drugs • Home Health • Skilled Nursing • DME

• Long-term services and supports • Medicare cost sharing (DME,

nursing home, prescriptions) • DME • Optional services (dental and

vision) • Home and community-based

services


• Claims adjudication and encounter processing is a critical operational process that must be managed, aligned and integrated downstream of and dependent upon many other functions and departments within managed care organizations (MCOs)

• Claims and encounter management consists of the following basic functions for the and its customers: o Authorization Requirements o Benefit Administration o Contract Administration o Eligibility and Membership

Administration

CLAIMS ADJUDICATION AND ENCOUNTER DATA PROCESSING

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o Finance Administration (i.e., Risk Sharing arrangements) o Information Technology and Configuration

• Ensures reimbursement methodologies such as capitation arrangements; fee for service; IPPS; OPPS; APC; DRG, HHRGS, RUGS, arrangements and other arrangements are configured in the core system.

• Upload and maintenance of all code sets required for processing medical claims/encounters (e.g. CPT-4; HCPCS; ICD -9/ICD-10CM Diagnosis and Services codes; Revenue Codes; PPS Codes; CCI edits; Place of Service Codes, Federal and State DRG codes and other Code Sets).

o Medical Management and Policy Administration o Provider Network Administration

CLAIMS ADJUDICATION AND ENCOUNTER DATA PROCESSING

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• Don’t say it if you don’t really mean it • Can you pay as Medicaid pays (or

Medicaid/Medicare)? o Provider fee schedule update

tracking and mirroring o Retrospective adjustments: Cost vs.

Prospective Payment System (PPS) o Bundling/Unbundling Contractual

Provisions o Add-on payments o Reimbursement primacy for Duals

claims o Provision for state tax/matching share

CONTRACTUAL REIMBURSEMENT

IMPACTS CLAIMS

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• We’ll settle up at the end of the contract term • Frequent audits against changes in contractual

reimbursement • Changes to provider allowable costs / Cost-to-Charge

Ratios (CCRs) under Medicare and Medicaid o Out-of-cycle fee schedule changes o Retroactivity and allowable cost revisions

CONTRACTUAL REIMBURSEMENT IMPACTS CLAIMS

Post-payment Issues

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WHAT IS CLAIMS LEAKAGE?


THE PATH TO AVOIDANCE

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BEST PRACTICE APPROACH • Path to avoidance:

o Invests in strong post-pay detection, as well as prepayment technology to deliver cost-avoidance savings

Avoidance focused: o Invests in targeted processes to

identify the root cause of financial leakage across the FWA spectrum


PROVEN STRATEGIES TO PLUG THE LEAKS

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PEOPLE Prepayment Audits

Post-payment Audits

PROCESS Workflow Improvement P&Ps DLPs

TECHNOLOGY

Configuration Business

Intelligence


CONFIGURATION HAS TO BE WELL PLANNED AND EXECUTED

It starts with a strong underlying framework that delivers the business requirements while maximizing system capabilities

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IT WILL REQUIRE CLOSE COOPERATION AND TEAMWORK

The configuration team needs strong input and direction from its business partners

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IT IS NOT WITHOUT RISK Configuration needs strong process controls and testing as well as

active validation of decisions

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IF EVERYONE PULLS TOGETHER,

WE SHOULD BE ABLE TO AVOID MAJOR DISCONNECTS

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THE GOAL IS TO OPTIMIZE

CONFIGURATION TO SUPPORT BUSINESS AND REGULATORY OBJECTIVES

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CONFIGURATION FRAMEWORK The Configuration Framework is composed of four dimensions, working

in alignment to manage business requirements as a strategic asset: People, Process, Technology, and Governance.

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People Governance

Process

Technology

Consistency Standardization Business Requirements Design Configuration Quality Review (CQR)

Build Test Technical Environment Data Analytics

Skills and Gaps Roles and Gaps Organizational Structure Employee Development

Governance Committee Information Management Configuration Ownership Dashboard Decision Support Objectives



IMPACT OF PROVIDER INCENTIVES AND PENALTIES ON MLR REPORTING

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• Bid Terms and Contract Language • Accrual of Payments and Penalties • Contractual vs. MLR Reporting Periods • Incurred But Not Reported (IBNR) Liability


• Operational Canaries o Pain Points o Key Performance

Indicators (KPIs) o Triggers

MONITORING THE PROVIDER NETWORK

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Monitoring Provider FWA • Move away from your desk and

don’t touch your computer • OIG priority for plans to monitor

providers and delegated entities o Set increase/decrease “triggers”

in claims volume by provider o Fraud detection software, batch

processing, cloud

FRAUD & ABUSE DETECTION UNDER DOWNSTREAM PROVIDER CONTRACTS


OIG FRAUD EFFORTS

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• Most common type of fraud perpetrated involves filing false claims for reimbursement.

• For April to September 30, 2014, OIG reported 506 criminal and 267 civil actions for health-care-related offenses.

• Frequently used exclusion and penalty authorities are described in Appendix D of the Semiannual Report and at the OIG Web site at: http://oig.hhs.gov/fraud/enforcement/cmp/.


PERFORMANCE METRICS

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• Why track performance? • What other’s track • Goal alignment • Operational approach

o Signifies maturity of Claims and Contracting

o Confidence that work is done o Measure quality

• Communication vehicle

DASHBOARD Organizational strategy around dashboards

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http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http://www.impactradius.com/blog/new-media-partner-dashboard-unveiled&ei=ByfmVJv2OomQyQSorYJA&psig=AFQjCNGWmeWshL4N35rty4nPpT0nCLxZRw&ust=1424455722005769


Top-down support for and the ability to instill a performance-driven culture is critical to Claims Operations and Network Management

PROMOTING BUSINESS ALIGNMENT

Ad Hoc and Reactive

Managed by Numbers and Proactive

Starting Point Desired State

Executive Focus

Metrics Definition

• Metric-based performance management framework with incentives management to exceed targets / goals

• Monitor and track their performance frequently

• Inconsistent engagement by leadership to manage business operations by the numbers

• Corporate culture has not embraced the adoption of complete configuration

Improve

• Targets / goals are established through industry benchmarks and historical performance

• Organizational targets / goals are defined and displayed on dashboards

• Compliance and some high-level vision metrics are defined and beginning to be adopted

• Minimal definition of enterprise and departmental level metrics

• Develop an Operations Governance Strategy

• Adopt configuration-driven management processes

• Establish accountability ownership of performance measures

Change Management

Change Management

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• ICD-10 Readiness and Remediation • Release Upgrade Assistance • Quality Assurance • System Optimization • Business Process and Operational Readiness

• System Procurement • Implementation Services • Project Management • Configuration and

Assessments • Conversion

OPERATIONAL PERFORMANCE & SYSTEMS SOLUTIONS

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OPEN DISCUSSION


Gorman Health Group, LLC (GHG) is a leading consulting and software solutions firm specializing in government health programs, including Medicare managed care, Medicaid and Health Insurance Exchange opportunities. For nearly 20 years, our unparalleled teams of subject-matter experts, former health plan executives and seasoned health care regulators have been providing strategic, operational, financial, and clinical services to the industry, across a full spectrum of business needs. Further, our software solutions have continued to place efficient and compliant operations within our client’s reach. GHG offers software to solve problems not addressed by enterprise systems. Our Valencia™ software reconciles the capitation payment of more than six million Medicare beneficiaries and continues to support customers participating in the Health Insurance Exchanges. Nearly 3,000 compliance professionals use the Online Monitoring Tool™ (OMT), our complete Medicare Advantage and Part D compliance toolkit, while more than 45,000 brokers and sales agents are certified and credentialed using Sales Sentinel™. In addition, hundreds of health care professionals are trained each year using Gorman University™ training courses. We are your partner in government-sponsored health programs

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MAE REGALDO Senior Consultant

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951.206.7316

[email protected]

DAVID GILES Senior Consultant

919.623.0690

[email protected]

mailto:[email protected]

mailto:[email protected]

Reimbursement comlexities in an evolving marketplace · 2018-05-24 · transforming its business...

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