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Medicaid Management

Medicaid Management. Stacy Calvaruso, CHAM Assistant Vice President – Patient Management, Ochsner Health System. Congressional Budget Office ……. Healthcare Reform is expected to result in Medicaid volumes growing from 39 Million to 55 Million eligible individuals by 2014.

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Medicaid Management

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  1. Medicaid Management Stacy Calvaruso, CHAM Assistant Vice President – Patient Management, Ochsner Health System

  2. Congressional Budget Office…… Healthcare Reform is expected to result in Medicaid volumes growing from 39 Million to 55 Million eligible individuals by 2014

  3. The Patient Protection and Affordability Care Act (PPACA) • Medicaid Application Processing • External Vendor • Internal Processes • Financial Counseling • Patient Profiling • Emergency Department Focus • Metrics to measure success • Denial Reports • Subsequent Visits Pro-Active Approaches to upcoming Medicaid Changes

  4. SE Louisiana's largest non-profit, academic, multi-specialty, healthcare delivery system • Named Consumer Choice for Healthcare in New Orleans for 15 consecutive years • Only Louisiana hospital recognized by U.S. News and World Report as a "Best Hospital" across seven specialty categories • 8 hospitals • 38 health centers in Louisiana • 12,500 employees • 850+ physicians in over 90 medical specialties • 300 clinical research trials annually Ochsner Health System

  5. Patient Protection and Affordable Care Act (PPACA) Commonly known as ‘Obamacare’ • Effective March 2010 • Specific provisions to be phased in thru 2020 • Effective April 2010 • Medicaid eligibility expanded to include all individuals and families with incomes up to 133% of the poverty level along with a simplified CHIP enrollment process.

  6. Patient Management Division • Hospital Patient Access Services • Clinic Patient Access Services • Pre-Service Center • Pre-Registration • Scheduling • Financial Counseling Patient Management and MEP Unit

  7. Healthcare Providers should take steps to increase their understanding of how existing processes may need to be altered in this environment. • Develop multidisciplinary teams that are dedicated to revising key procedures. • As a part of overall Healthcare insurance reform programs, there will be a renewed and aggressive nature of reimbursement audits • Close scrutiny of the referral and authorization process. • Many facilities already struggle with this process and Ochsner was no different. SWOT - Program Impact

  8. Reduced Authorization and Eligibility Denials • Ensure consistent financial clearance • Improved POS Collections • Pre-service patient notification and education • Improved Revenue – • Fewer delays for Financial Clearance • Decrease Bad Debt Volume – Proactive identification of options and resources for the patient’s out of pocket liability • 100% screening for Medicaid eligibility • Charity care based on a sliding scale • Prompt pay discounts • Propensity to pay evaluation • No-interest payment plans Overall Objectives

  9. 2010Results Outside Vendor • 6734 Applications • No ED Coverage • No Clinic Coverage • Very limited on-site presence 1 -Medicaid Application Process

  10. State Certification for Financial Counselors to accept applications • 8A – 19P E D coverage • 1 year agreement with new vendor to teach us how to expand our knowledge • Deep Dive into demographics surrounding each facility • Extensive work-flow development • Comprehensive training Medicaid Application Center

  11. Pre-Service Center • Emergency Department • Mobile to Bedside • Clinical Partner • Various Clinics • Part of treatment team for high $ • Walk-in’s • Open to the Public Financial Counseling – Required!

  12. Based on data elements • Age, income, and zip code • Considerations • Estimated cost of care and patient out of pocket • Propensity to Pay • The likelihood of eligibility for financial assistance • Financial clearance staff provide “financial informed consent” • patterned after standard pre-surgical informed consent • seeks to educate each patient about coverage benefits • Other options • 0% Interest Payment Plans • Charity Care, Financial Sponsors, Community Resources, etc. Patient Profiling?

  13. Registration • Eligibility Tool with 270/271 expanded information return • 3rd Party Payor Options • Victim’s Compensation • Local Charities • Social Security / Disability • COBRA • Profiling again… Query Medicaid • Medicare primary • Self Pay over 45 yrs old if unemployed • Inform patients of Medicaid enrollment opportunities • Prioritize screening and enrollment efforts based on expected clinical outcomes / future needs Prepare for Medicaid Growth

  14. Eligibility Program Results The results include approvals, founds coverage and subsequent visits: Approvals/Founds • Number/Quantity - 15,246 approvals • Gross Charges - $57.9 million • Net Revenue - $13.3 million

  15. SubsequentVisits Number/Quantity - 19,961 visits Gross Charges - $96.0 million Net Revenue - $21.4 million

  16. Program Results for FY 2011 Gross Charges - $153.9 million Net Revenue - $34.7 million (net expected reimbursement)  Program Cost - $7.5M (est)

  17. 2 - Medicaid Auth Task Force Objectives Understand weaknesses in current process Prepare for increase in Medicaid administrative paperwork Improve communication and accountability Reduce Denials Reduce YAA’s Expand to areas with missing auth related items

  18. Expected ROI on project Year 1 Reduction of $9M of Gross Charges in denials Year 1 Reduction of $2.37M in YAA Savings to organization Year 1 = $2.2M Year 2 = $1.37M Year 3 = $853K Total = $4.46M Estimation of 60% reduction in denials over 12 month period in year 1 based on Oct-Dec denials received. Savings reduced by Database & FTE salaries for 2012.

  19. Medicaid Denials September thru October 2011 Results Top10 Denial Reasons Gross charges denial amount

  20. Medicaid Denials September - October 2011 Results Top10 Denial Reasons CO-140 PCP Authorization Missing/Invalid CO-197 Pre-Cert Authorization Missing Gross charges denial amount

  21. First Step - Identify who does what Utilization Mgmnt Pre-Service Center Admit Department

  22. Second Step – Identify root cause? Lack of Automation, Communication, and Follow-thru Lack of Denial data specific to PM areas Lack of automation Documentation in multiple places Inability to know who was assigned to a patient Complex rules and requirements Rotating staff Leadership challenges Not my job syndrome!

  23. How should we resolve the issue? Use the data to determine what we are doing wrong Denials Claim hold volume YAA’s Determine who should ‘own’ the process Admissions Utilization Management Fix the problem! 2nd Step - Remove the excuses!!

  24. Denial Data Review All Denials received October thru December 2011 ( Regardless of Admit Date )

  25. Denial Data Review Admit date priorto 10-1-11 Denials received in October – December 2011 Gross Denial Amount

  26. Team Resources

  27. Map out current flow • Include key stake holders in improvement discussion • Identify failures without pointing fingers • Identify needs on how to improve Take Action!

  28. Taking Action…..

  29. October – December Denials Gross denials and the resulting YAA posted for DOS after October 1, 2011

  30. Metrics to be monitored • Performance Measurement • Ins Ver Secure Rate (Scheduled) • Ins Ver Due Diligence Complete Rates (Non-Scheduled) • PreReg Completion Percentage • Ins Ver and PreReg Days Out • Authorizations Obtained/Completed • Financial Counseling Sessions Completed • 100% Inpatient • 90% Emergency Department • 80% Outpatients with Bad Debt and/or High Risk Score • B/D and Charity Care Adjustments • Claim Edits, Rejections, and Denials • Yield Affecting Adjustments

  31. Lessons Learned Leveraging technology is crucial to achieving high performance standards in a volume-driven environment and the increase of Medicaid patients will impact those who are not ready. The lack of collaboration across service teams will negatively affect organizations resulting in the following: Loss of Revenue due to denials that result in Yield Affecting Adjustments Lack of automation to fully assist with cross-department work flow Poor communication between the various department Inefficiencies that result in rework across the revenue cycle

  32. Questions?

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