Managing your growth in unmanageable time.

1. Managing your growth in unmanageable time. Aaron Burky Director, Transitional Operations Conifer Health Solutions

2. Agenda Topics

3. From then until now….. • Managed Medicaid Penetration • National • 2002 57.5% 23.1MM recipients • 2011 74.2% 42.3MM recipients • Texas • 2011 70.7% 2.7MM recipients • Steady growth even without ACA funding Medicaid expansion • 2014 and now it looks like this.. • ACA funding Medicaid expansion in 26 states, with 4 still considering (20 not considering at this time) • Federal Government involvement allows states to offer Medicaid coverage up to 138% of FPL • Expected to add 4-7MM recipients in expansion states in 2014 alone • Non-expansion states still expanding to Medicaid Managed Care • Value of budget predictibility • TX—Over 10% of population expected to be a recipient of Medicaid Managed Care

4. Payer changes • Payer patient plan options • HMO/PPO/Health Exchange • Ability to switch plans as much as monthly in some cases • Additional enrollment documents and processing • Texas—enroll with TMHP first, then with MCO • Payer provider reimbursement changes per plan • Importance of monitoring appropriate reimbursement • Government payer—Compliance impact • Understanding of higher number of payers • Understanding deductibles and POS policies for different payers • Have to operationalize these differences to be effective • What can we expect and how can we differentiate which plan is chosen? • Patient advocates—be proactive

5. Key Performance Indicator Suggestion • Understand patient mix • Track and trend all elements of the life cycle of the claim • Contracting • Use analytics in negotiations—understand entire organizational performance to KPIs • What are the causes of not obtaining optimal reimbursement? • Pre-billing • Patient Access, coding, billing edits • Post-billing • Cycle times at payer, denials, underpayments • Post-payment • Effective methods of post payment audit and review • Hold payers accountable to contract terms

6. The hit of a conversion…. What to expect or not expect? • What can you expect? • Dictionary Challenges • Billing edit variances • Cash flow sustainability • DNFB new user training. • Vendor movement reduction • Not just benefit of DSH/Non-profit/Safety-net hospitals, 1/3 drop in 1stqtr 2014 of uninsured at investor owned systems • Patient Mix changes • Higher relative ER volumes—survey by American College of ER physicians shows no overall change in ER volumes, but 35% increase in Medicaid ER

7. Best Practices • Trending and Tracking • Clinical nurse • Managed Care/Contracts involvement • Network with other providers • Know your laws/statutes • EMTALA—higher ER volumes • Patient Advocacy • Find Medicaid patients a PCP so they don’t have to use the ER • “Safety-net” hospitals that treat a disproportionate share of poor and uninsured benefit • Take advantage of drop in uninsured and capitalize • Use to offset Medicare cuts

8. Case Study • 453 Bed Acute Care Facility in KY • $310MM annual NPSR • KY is an expansion state with an already high Managed Medicaid penetration rate of 90% • Disputes • 1st quarter 2012 • 650 visits/month Managed Medicaid • 286 denials/month • 1st quarter 2014 • 900 visits/month Managed Medicaid • 820 denials/month • How to resolve: • Track and trend • Consistent billing edit review—engage vendor partners and leverage their experience • Legal involvement • Specific laws related to ER visits • Held payer accountable • Work items in bulk

9. What does the future hold? 2014 Beyond ACA picks up the tab for expansion for 3 years What happens next? Are we back to current state or is that long enough to correct Continued importance of KPIs, Contracts and Payer performance monitoring • Large increase of Managed Medicaid • Uncertainty in effectiveness of system • Vitally important contract negotiations

10. Thank you Aaron Burky Conifer Health Solutions 469-803-3875 Aaron.burky@coniferhealth.com