Reimbursement Challenges to the Receipt of Confidential Reproductive Health Services Joanne Armstrong, MD, MPH Aetna March 13, 2008

2 Aetna  National health benefits company –16 million medical members, all 50 states  Network of contracted physicians, hospitals and laboratories –470,000 primary care physicians and specialists –4,771 hospitals –48 laboratories  Wide array of health plans offered –HMO, PPO, Health Savings Accounts –Benefits designs vary

3 Health Plan Functions  Contract with providers to optimize the cost of care on behalf of customers  Provide tools and services to help optimize the quality and effectiveness of care –Wellness programs, HEDIS programming, etc.  Pay claims –Reimbursement based on plan design and benefit design  HMO, PPO, Health Savings Accounts  Co-pay, deductibles  All operations occur in a complex, and sometimes conflicting, array of federal and state regulations and mandates

4 Minor Consent Laws for Reproductive Health Services  No federal laws  Every state has a mandate to authorize minors to consent to medical care, but no uniform mandate  Minor status classification based on variables not available to insurers  Demographic variables - marital status, HS graduate, armed forces service  Medical condition or category of care needed - pregnant or pregnancy related, contraceptive services, STD care, HIV  Consent status of adolescents is not known or knowable by insurers at the time care is reimbursed

5 Consent and Confidentiality vs. Reimbursement  Mandate for consent ≠ mandate to protect confidentiality –Some, but not all, state laws that authorized minors to consent to care restrict disclosure of that information without permission  Mandate for consent and/or confidentiality does not assure reimbursement –Most laws that authorize minors to consent for care do not make provisions for payment of services or remove obligation to pay for them  Reimbursement requirements create a “paper trail” –Reimbursement flows through insurance plan and benefit design –Federal and state laws regulating reimbursement require disclosure of at least some personal health information

6 Federal Laws Regulating Correct Billing and Reimbursement Health Insurance Portability and Accountability Act (HIPAA, 1993), Electronic Transactions Regulations (2003) –Title II, Subtitle F of HIPAA-Administrative Simplification and Privacy  Requires standardized formats and data content in electronic exchange of information in health plan operations: –Claims submission, payment, and inquiries –Referrals and authorizations –Enrollments –Premium payments and coordination of benefits

7 HIPAA Code Sets Regulations require the use of standardized medical code sets –ICD-9-CM Codes- International Classification of Diseases, 9th Edition; maintained by HHS –NDC Codes – National Drug Codes; maintained and distributed by HHS, in collaboration with drug manufacturers. –CPT-4 Codes – Current Procedural Terminology, Fourth Edition; maintained and distributed by the American Medical Association. –HCPCS – The Healthcare Common Procedure Coding System; maintained and distributed by HHS.  The Code Sets Regulations prohibits use of homegrown codes or standard codes using non-standard definitions  Non-specific coding is permitted but discouraged because of loss of detailed claims experience to guide health plan operations, contracting, and other functions

8 HIPAA HIPAA applications are broad  All health plans (i.e. HMOs, health insurers, group health plans, including self-funded plans), health care clearinghouses, and health care providers who transmit member health information in electronic form  All clinical transactions  All insured members –No exceptional status for adolescents wrt correct coding

9 HIPAA in Action  HIPAA –Providers (clinicians and laboratories) must code accurately and consistent with ICD9 and CPT methodologies –Laboratories cannot change diagnosis or procedure codes provided by clinician –Health plan cannot change diagnosis or procedure codes billed by laboratories or clinician –HIPPA applies to all clinical content and all insured individuals  Correct coding regulations limit ability to “mask” confidential adolescent health care services

10 State Laws Regulating Communication of Benefits to Insured Members  Explanation of benefits (EOB) are required for all member claims transactions if insured has some financial liability for care  Content of EOBs regulated by States  EOB must include: –Provider name –Service date –Broad category of service (laboratory, hospital)  Sensitive claim information such as procedure codes or specific type of service, and certain provider types, are not displayed on EOBs  No suppression of EOB or content of EOB allowed

11 State Laws Regulating Communication of Benefit to Insured Members  The EOB must accurately and clearly disclose the benefits payable under the contract and how they were calculated –Amount charged by the health care provider –Amount allowed by the insurer –Amount paid by insurer –Notation of the amount of member liability (difference between the amount charged and the amount allowed by the insurer) –Applicable deductible and co-payment amounts –Claim adjustment reason codes and narrative explanation  Only transaction exempted from EOB is in HMO setting where co-pay is the only financial obligation of insured

12 Member EOB

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14 Member Explanation of Benefits  EOBs are addressed to plan subscriber, not covered dependents  EOBs can be sent to separate address, if requested by any member covered under the plan  But, any financial information related to health savings accounts (HAS) or flexible spending accounts (FSA) must be provided to subscriber –Remaining deductible –Lifetime limits

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17 Where to go from here?  Reimbursement regulations undermine confidentiality efforts  Confidentiality “work-arounds” are not fool proof and not practical for adolescents  Provider education regarding billing strategies will have limited success  The availability of innovative tools to identify non- compliant teens for screening are available but use is limited by confidentiality concerns

New Approaches to CT Screening Adherence Demo/Psycho -graphic Data Claims Data Mx, Rx, Lx Eligibility Data Plan Design External Data Bases HRA EMD Member Self Reported Data MDHospital Dentist CareEngine ® Evidence Based Algorithms Member Health Profile Wellness counseling Personal Health Record sends alert to member about a gap in care Delivery to Member and Providers

19 Personal Health Record

20  Vascular  Peripheral Artery Disease (PAD)  Cerebrovascular Disease (CVA)/Stroke  Congestive Heart Failure (CHF)  Coronary Artery Disease CAD)  Diabetes – Adult and Pediatric  Hypertension (high blood pressure)  Hyperlipidemia (high cholesterol)  Pulmonary  Asthma – Adult and Pediatric  Chronic Obstructive Pulmonary Disease (COPD)  Gastrointestinal  Gastro Esophageal Reflux Disease (GERD)  Chronic Hepatitis  Peptic Ulcer Disease  Inflammatory Bowel Disease (Crohn’s Disease and Ulcerative Colitis)  Neuro-Geriatric  Seizure Disorder  Migraine  Parkinsonism  Geriatrics  Orthopedic  Rheumatoid Arthritis (RA)  Osteoporosis  Osteoarthritis (OA)*  Cancer  General Cancer  Breast Cancer  Lung Cancer  Lymphoma/Leukemia  Prostate Cancer  Colorectal Cancer  Renal  Chronic Kidney Disease  End Stage Renal Disease  Other  Cystic Fibrosis  HIV  Hypercoagulable State  Chronic Low Back Pain  Sickle Cell Disease - Adult and Pediatric  Weight Management  Chlamydia screening Program Conditions/ Clinical Content

21 Chlamydia Care Consideration  Screens female membership ages for evidence of sexual activity and chlamydia screening  Sends via mail or Personal Health Record messaging a care consideration: –“Women 24 years old or younger who are sexually active should get tested for chlamydia every year. –Chlamydia can cause an infection of the reproductive system which can lead to infertility and problems with future pregnancy. –Chlamydial infection does not always cause symptoms, so it is important to get tested if you are sexually active. –Ask your doctor if you should have this test.”

22 Thank You