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

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Presentation on theme: "Medicaid Management Stacy Calvaruso, CHAM Assistant Vice President – Patient Management, Ochsner Health System."— Presentation transcript:

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 Pro-Active Approaches to upcoming Medicaid Changes 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

4 Ochsner Health System 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

5 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. Patient Protection and Affordable Care Act (PPACA)

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

7 SWOT - Program Impact 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.

8 Overall Objectives 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

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

10 Medicaid Application Center 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

11 Financial Counseling – Required! 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

12 Patient Profiling? 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.

13 Prepare for Medicaid Growth Registration Eligibility Tool with 270/271 expanded information return 3 rd 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

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15 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 Eligibility Program Results

16 Number/Quantity - 19,961 visits Gross Charges - $96.0 million Net Revenue - $21.4 million Subsequent Visits

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

18 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 2 - Medicaid Auth Task Force Objectives

19 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 Expected ROI on project

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

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

22 First Step - Identify who does what Pre-Certs Referrals Authorizations Benefit Verification Pre- Registration Financial Clearance Initial Payor Notification Initial Pre- Certification Benefit Verification Payment Arrangements Registration Referrals Continued Stay Reviews Initial Clinicals Facilitates Peer to Peer D/C assistance Confirms appropriate status Pre-Service CenterAdmit Department Utilization Mgmnt

23  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! Second Step – Identify root cause? Lack of Automation, Communication, and Follow-thru

24 2 nd Step - Remove the excuses!! 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!

25 Denial Data Review All Denials received October thru December 2011 ( Regardless of Admit Date ) TOTAL NON-AUTH & ELIGIBILITY DENIALS Denial CategoryCountDollars Eligibility 1,768$5,611,989 Non-Auth/ MCD Non-Covered 88$539,055 Non-Auth/ No PCP Referral 1,452$1,384,250 Non-Auth/ Precert 605$8,786,058 Grand Total 3,913$16,321,352

26 Denial Data Review Admit date prior to Denials received in October – December 2011 Gross Denial Amount TOTAL NON-AUTH & ELIGIBILITY DENIALS Denial CategoryCountDollars Eligibility 1,197$3,682,139 Non-Auth/ MCD Non-Covered 54$423,483 Non-Auth/ No PCP Referral 976$944,164 Non-Auth/ Precert 399$5,605,116 Grand Total 2,626$10,654,903

27 Team Resources

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

29 Taking Action…..

30 October – December Denials TOTAL NON-AUTH & ELIGIBILITY DENIALS ADMIT DATE BEFORE/AFTER 10/1/11 NON-AUTH & ELIGIBILITY DENIALS RESULTING IN A YAA ADMIT DATE BEFORE/AFTER 10/1/11 Denial CategoryCountDollarsCountDollarsAdj Amount DOS After 10/01/11 1,287$5,666,44938$517,384($36,915) Eligibility571$1,929,85021$276,508($737) Non-Auth/ MCD Non-Covered34$115,5723$12,031($49) Non-Auth/ No PCP Referral476$440,0863$2,045($4,397) Non-Auth/ Precert206$3,180,94211$226,800($31,732) DOS Before 10/01/11 2,626$10,654,903252$363,665($269,859) Eligibility1,197$3,682,139102$105,675($14,859) Non-Auth/ MCD Non-Covered54$423,4834$11,333($291) Non-Auth/ No PCP Referral976$944,164126$91,916($220,807) Non-Auth/ Precert399$5,605,11620$154,741($33,902) Grand Total 3,913$16,321, $881,049 ($306,774) Gross denials and the resulting YAA posted for DOS after October 1, 2011

31 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 Metrics to be monitored

32 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 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:

33 Questions?


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