Navigating the Waters of Health Care Reform and Keeping your Health Care Plan Afloat Jim Williams, Benefit Specialist

Health Plan Provider Fraud & Abuse Health Plan Pressures

30% of all medical bills contain errors -Stephen Parente, professor of health finance at the University of Minnesota Fraud & Abuse

Health Plan Provider Fraud & Abuse Escalating Costs Health Plan Pressures

Escalating Costs

Health Plan Provider Fraud & Abuse Escalating Costs Technological Advancements

 Specialized Radiology  Genetic Testing  Robotics

Health Plan Provider Fraud & Abuse Escalating Costs Technological Advancements Rx Costs & Advancements

Rx Costs  In 1990, as a percentage of the total plan cost-10%  In 2011, as a percentage of the total plan cost, this has grown to 25%

Rx Costs Contributors to Rx Costs  Double Digit Inflation  Specialty Medications  Sole Source Brand Name Medications  Direct Patient Marketing Consumer Choice = Less Cost Effective Choices Physician Over Prescribing

Health Plan Provider Fraud & Abuse Escalating Costs Technological Advancements Rx Costs & Advancements Over Charging & Unbundling

Bundled vs. Unbundled Dialysis Claim Comparison Original Bundled Charges AWAC Savings

Health Plan Provider Fraud & Abuse Escalating Costs Technological Advancements Rx Costs & Advancements Over Charging & Unbundling Treatment Protocol Changes

 Off-Label Use of Medication  Physician Dispensing

Health Plan Provider Fraud & Abuse Escalating Costs Technological Advancements Rx Costs & Advancements Over Charging & Unbundling Treatment Protocol Changes Participant Expectations

 100% Coverage  100% Employer Paid  No Out of Pocket Expenses  Utilize any Physician, Hospital, or Clinic  No Pre-Existing Condition Exclusions  Enrollment Upon Demand Participant Expectations

Health Plan Provider Fraud & Abuse Escalating Costs Technological Advancements Rx Costs & Advancements Over Charging & Unbundling Treatment Protocol Changes Participant Expectations PPACA

 No Pre-Existing Under Age 19  Children Covered Until Age 26  Elimination of Lifetime Cap  Elimination of Annual Cap  Out of Pocket Expense Cost Sharing  Deductible Cost Sharing  Premium Cost Sharing PPACA

Keeping Your Health Plan Afloat Wellness Pre- Certification/Case Management Disease Management Claims Administration Rx Management Reporting Communication data

 Health Risk Assessment  Biometric Screening  Education-Goal Driven  Rewards Results Participation  ROI- $1 of Investment = $3 of Return Over 3 Years Wellness

 Early Notification  Collection of Relevant Information  Alert Plan to Issues (off label use)  Initiation of Case Management  Case Managers Professional Accreditation Effective Communication w/Plan, Participants, & Providers Aggressive Management & Negotiation Pre-Certification Case Management

 Patient Focused  Physician Driven  At the front of the Health Care Continuum  Frequent & Direct Communication w/Plan, Participants, & Providers  Examples: Cancer, Heart Disease, Diabetes, etc. Disease Management

 Patient Focused  Effective Use of Technology Enhances Access to Information for Patients, Providers, & Plan  Low Error Rate  Prompt Turnaround  Captures All Claims Data  Interfaces with all segments of Plan Claims Administration

 Specialty Drugs Rx Plan Health Plan Combination  Mail Order  Forcing Generics w/MAC Pricing  Properly & Precisely Defined AWP  Personal Communications of Plan Design to Participants  Assist Individual Participants w/ Prescription Choices including Physician Communication  Data…Data…Data Rx Management

Reporting “ If you don’t know how you are spending your Health Care dollars, you CANNOT properly and effectively manage and contain your costs. ” “ He who controls the data controls the plan. ”

 “ A well designed plan that is not properly utilized by the participants will not operate efficiently and economically for anyone. ”  Participants must understand the plan and how to use it  Must be often and consistent  Must include participants and providers  60 day prior notice of changes Communication

Summary Whether you are fully insured or self-funded, you should have these components as a part of your Health Plan. Self funding allows the Plan Sponsor more flexibility in the design of benefits and selection of management tools. Be Aggressive-Make your Benefits Consultant,TPA or Agent, work for their pay.

Health Care Reform, PPACA or by whatever name you know it by, is only a threat to the operation of your Health Plan if you allow it. Your Benefit Consultant, TPA, or Agent does not have all the answers, however, together with an involved and informed Plan Sponsor, you can maintain a cost effective Health Plan that provides quality benefits to its participants.

P.O. Box 1688 Pascagoula, MS (228) Phone (800) Toll Free (228) Fax