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Managing your growth in unmanageable time. AARON BURKY DIRECTOR, TRANSITIONAL OPERATIONS CONIFER HEALTH SOLUTIONS.

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Presentation on theme: "Managing your growth in unmanageable time. AARON BURKY DIRECTOR, TRANSITIONAL OPERATIONS CONIFER HEALTH SOLUTIONS."— Presentation transcript:

1 Managing your growth in unmanageable time. AARON BURKY DIRECTOR, TRANSITIONAL OPERATIONS CONIFER HEALTH SOLUTIONS

2 Agenda Topics From then until now… growth year over year Fluctuation in payer practices Using Key Tools or KPI’s to manage The hit of a conversion…. What to expect or not expect? Best Practices in a ever changing world Brief Case Study What does the future hold and how can we manage it

3 From then until now…..  Managed Medicaid Penetration  National  % 23.1MM recipients  % 42.3MM recipients  Texas  % 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 1 st qtr 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  1 st quarter 2012  650 visits/month Managed Medicaid  286 denials/month  1 st 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  Large increase of Managed Medicaid  Uncertainty in effectiveness of system  Vitally important contract negotiations 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

10 Thank you AARON BURKY CONIFER HEALTH SOLUTIONS


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