Operationalizing Global Contracts

1. Operationalizing Global Contracts The Children’s Healthcare of Atlanta Experience Joyce M. Davis Transplant Fiduciary Manager

2. Objectives • Define • Local transplant contractual agreements • Transplant spot agreements • Transplant global agreements • Transplant global spot agreements • Share Children’s Healthcare of Atlanta global contracting experience. • Where Children’s began • Where Children’s is today

3. Children’s Healthcare of Atlanta

4. Our Mission • Children’s Healthcare of Atlanta enhances the lives of children through excellence in patient care, research and education. Serving our community with more than 30 pediatric specialties, Children’s is committed to being a model for pediatric care. • Children’s provides access to care through: • 􀂃 • 474 staffed beds 􀂃 • 15 neighborhood locations throughout metro Atlanta, including: 􀀹 • Five Immediate Care Centers􀀹 • One Primary Care Center 􀂃 • More than 6,700 employees􀂃 • Access to more than 1,400 pediatric physicians • 5,900 volunteers

5. Solid Organ Transplant • Transplant Children’s performs liver, heart and kidney transplants. The Children’s Healthcare of Atlanta Carlos and Marguerite Mason Transplant Center provides outpatient and specialty services in one centralized location. • Volumes􀂃 In 2007, Children’s performed 25 liver transplants, 12 heart transplants and 19 kidney transplants. • Awards Since 2000, Children’s has ranked among the country’s top 10 pediatric hospitals for solid organ transplant volumes according to the United Network for Organ Sharing (UNOS).

6. Blood and Marrow Transplants • Transplants The Aflac Cancer Center and Blood Disorders Center of Children’s Healthcare of Atlanta is a national leader among childhood cancer, hematology and blood and marrow transplant programs serving infants, children, teenagers and young adults. • Volumes The Aflac Cancer Center performs more than 50 blood and marrow transplants annually, making it one of the leading pediatric BMT programs in the country. In 2007, the Aflac Cancer Center performed 57 allogeneic and autologous BMTs. • Awards The Aflac Cancer Center is ranked as one of the top five pediatric cancer programs in the country by Child Magazine.

7. Transplant Fiduciary Children’s Transplant Programs Volunteers GI Kidney Surgeon Social Work Pediatric Anesth. Hem/Onc PICU Radiology Adult Donors CICU Heart Surgeon Hepatology Cath Lab Tx Clinic Hospital Nursing Cardiology Liver Surgeon Nephrology Nutrition

8. Children’s Fiduciary Agreement • What is the Fiduciary Agreement? • The Fiduciary Agreement is an arrangement between Children's Healthcare of Atlanta, Inc. and Emory Healthcare, Inc. on behalf of hospital and physician providers within each organization for the purpose of contracting with payors to provide pediatric transplant and transplant related hospital and physician services provided to patients at Egleston for each contract where there is a global rate established for reimbursement.

9. Fiduciary Agreement continued • Who are the “Parties” to the Fiduciary? • Egleston Hospital (ECH) • Egleston Pediatric Group (EPG) • Egleston Affiliated Services (EAS ) • Scottish Rite Children’s Medical Center (SRCMC) – Physicians Only • Children’s Sedation Services (CSS) • Sibley Heart Center Cardiology (SHCC) • The Emory Clinic (TEC) • Emory Children’s Center (ECC) • Emory University Hospital (EUH)

10. Fiduciary Agreement continued • How does the Fiduciary Agreement work? • The Fiduciary Agreement is structured so that the coordination of financial counseling, service authorization, billing, collecting and distribution of payments to the parties for pediatric transplant and transplant related hospital and physician services provided under global rate reimbursement arrangements are centralized. The coordination of these functions necessitates the creation of a centralized position (“fiduciary”) to facilitate the activities among the parties

11. Fiduciary Agreement continued • Why is the Fiduciary Agreement Necessary? • Children’s solid organ transplant teams consist of transplant surgeons and other specialty providers that are either employed or contracted by Emory. The Fiduciary Agreement provides Children's the ability to negotiate pediatric transplant contracts through a single source under single signature authority through Children’s Managed Care Department. Thus, payors seeking pediatric transplant services at Children’s do not need to seek separate contracts with Emory or other providers that are parties to the Fiduciary Agreement. For global reimbursement contracts with payors, contract negotiations, financial counseling, service authorization, billing, collecting and distribution of payments are all done by Children's.

12. Referrals • Transplant Financial Counselors • Obtain critical transplant benefit information • Local agreement • Spot agreement • Global agreement • Spot global agreement

13. Local Agreement • Hospital and physician contract in place which includes or does not specifically exclude transplant services

14. Spot Agreement • Hospital and or physicians are out of network. • Requires individual case negotiation between provider and payor

15. Spot Global Agreement • Hospital and physicians are out of network • Requires individual case negotiation between providers and payors • Contract terms modeled to mirror a global agreement

16. Global Agreement • Hospital and physicians contracted for transplant based on a model with specific transplant phases of care

17. Transplant Phases of Care • Evaluation phase • Definition – phase of treatment at the initiation of health services which includes testing and consultations to determine if patient is a suitable candidate for transplantation • Pre-transplant phase • Definition – phase of treatment which immediately follows evaluation phase as patient awaits transplantation and ends at the initiation of the transplant phase • Transplant phase • Definition –phase of treatment which the patient is admitted for treatment for the purpose of receiving a solid organ or blood and marrow transplant • Post transplant phase • Definition – phase of treatment which the patient has been transplanted and has began to receive follow up care

18. Reimbursement • Cha-Ching $$$$$$

19. Reimbursement • Global case rates • Designed to pay a fixed amount for both hospital and physicians for a specified length of stay which may include inliers language, outlier language, a reimbursement floor or stop loss provision.

20. Children’s Experience • First global case • May of 2002 • All phases of care bundle billed to payor • Claims lost repeatedly • No method to track claims re-priced by the network • Claims resubmitted repeatedly • A/R increased • Reconciliation completed over the phone • Explanation of benefits single line item

21. Children’s Experience Operation Improvements • Set up mandatory meetings with all provider billing office • Developed reports for outstanding A/R • Developed reports for overpayments • Developed reports for denials

22. Children’s Experience • Educated system leadership on complexity of global contracts • Exclusions • Carve outs • Payment disbursements

23. Children’s Experience • Established routine meetings with Managed Care • Provided re-pricing and payment turnaround time data to ensure contract language was honored

24. Children’s Experience • Educated Patient Access Staff • Insurance plan codes • Spot agreements • Global agreements • Global spot agreements

25. Children’s Experience • Educated Utilization Management Staff • Insurance plan codes • Global authorizations

26. Children’s Experience • Collaboration with Patient Financial Services • Dedicated Transplant Accounts Receivable Coordinator • Educated Cash Posting Staff • Educated Variance Staff

27. Children’s Experience • Established Transplant Fiduciary Team • Solid Organ TFC • Blood and Marrow TFC • Transplant Operations Anlayst • Lead Patient Access Specialist • Lead Insurance Verifier • Patient Access Specialist

28. Children’s Experience • Where we are today • Contracting • Operationally friendly • Bundle bill transplant phase only • Leadership • Educated and on board • Fiduciary Team • Stellar • Patients • Satisfied

29. Questions • Thank You!