How to Safely Navigate the River of Cash

Transcription

1 How to Safely Navigate the River of Cash LeadingAge NY Financial Managers Conference August 2016 Navigation Considerations Know your river Maneuver around obstacles Strainers enrollment and authorizations Sweepers audits and insurance verification Eddies payor requirements and collections Hydraulics appeals and denial management Sandbars NAMI collection and self pay Thorough trip planning Page 2 1

2 Know your river looks can be deceiving Page 3 Medicare Advantage Since 2010 national enrollment increased by 30% July 2016: 1.28 million NY enrollees (38% penetration) 15 counties with < 25% penetration o Clinton, Dutchess, Essex, Franklin, Nassau, Orange, Otsego, Putnam, Rockland, St. Lawrence, Suffolk, Sullivan, Tompkins, Ulster and Westchester 11 counties with > 50% penetration o Bronx, Erie, Genesee, Livingston, Monroe, Niagara, Ontario, Orleans, Wayne, Wyoming and Yates Reports/MCRAdvPartDEnrolData/MA-State-County-Penetration-Items/MA-State-County- Penetration html?DLPage=1&DLEntries=10&DLSort=1&DLSortDir=descending Page 4 2

3 New York Medicare Advantage (July 2016) Reports/MCRAdvPartDEnrolData/Monthly-MA-Enrollment-by-State-County-Contract-Items/MA- Enrollment-by-SCC html?DLPage=1&DLEntries=10&DLSort=1&DLSortDir=descending # of Counties # of Contracts and Plans Page 5 Medicare Advantage I-SNP I-SNP = Institutional Special Needs Plan Restricts enrollment to Medicare Advantage eligibles who for 90+ days have had or are expected to need SNF/NF, ICF/MR or inpatient psychiatric facility services Provides extra care coordination and preventive services benefits in addition to regular Medicare Advantage plan benefits o January 2016 UHC blocked by NYS Attorney General from requiring some SNFs in its commercial-plan provider network to join the I-SNP network Page 6 3

4 New York I-SNP (July 2016) # of Plans # of Reported Enrollees ,029 Affinity, Agewell NY, Alphacare, Amida, Atlantis, Catholic Special Needs, Centerlight, Centers Plan, Cuatro, Elderplan, Elderserve, Empire Health Choice, Fallon Health Weinberg, Group Health Inc, Guildnet, HIP, Healthfirst, Humana, IHA, Liberty Health, MetroPlus, Quality, Senior Whole Health, NYS Catholic Health Plan, UHC, VNS Choice and Wellcare Reports/MCRAdvPartDEnrolData/Special-Needs-Plan-SNP-Data-Items/SNP-Comprehensive- Report html?DLPage=1&DLEntries=10&DLSort=1&DLSortDir=descending Page 7 Medicaid Managed Care MLTC Managed Long Term Care Plan Long term care and home care services Medicare/Medicare Advantage stays in place Mandatory for dual eligibles MA Medicaid Advantage Includes Medicare services but Medicaid coverage without LTC MMCP Medicaid Managed Care Plan (mainstream) Managed care version of Medicaid and covers LTC Mandatory for most Medicaid recipients dual eligibles are excluded Page 8 4

5 Medicaid Managed Care MAP Medicaid Advantage Plus Traditional insurance model for age 18+, intensive case management model If required to enroll in MLTC may choose to enroll in a MAP Must enroll in the plan s Medicare product Limited plans across the state Page 9 Medicaid Managed Care FIDA (Fully Integrated Dual Advantage) Both Medicare and Medicaid services, including Part D Rx Builds upon existing MLTC program Bronx, Kings, Nassau, New York, Queens, Richmond, Suffolk and Westchester (delayed roll-out to Suffolk and Westchester) Passive enrollment suspended December 2015 May 2016 enrollment dropped to 5,370 FIDA-IDD (Intellectual and Developmental Disabilities) Partnership with NYSDOH and OPWDD for dual-eligible enrollees Demo slated to run through December 2020 Bronx, Kings, Nassau, New York, Queens, Richmond, Rockland, Suffolk and Westchester Page 10 5

6 Medicaid Managed Care HARP Health and Recovery Plan Specialized integrated product line for people with significant behavioral health needs Eligible based on utilization or functional impairment Must be insured only by Medicaid and eligible for Medicaid managed care What HARP s do: o Manage Medicaid services for people who need them o Manage and enhanced benefit package of Home and Community- Based Services (HCBS) o Provide enhanced care management to help coordinate all physical health, behavioral health and non-medicaid support needs Page 11 Medicaid Managed Care PACE (Programs of All-Inclusive Care of the Elderly) Provides a comprehensive system of health care services for members age 55 and older who are otherwise eligible for nursing home admission Both Medicare and Medicaid pay for PACE services (on a fullcapitated basis) PACE members are required to use PACE physicians and an interdisciplinary team develops care plans and provides ongoing care management PACE is responsible for directly providing or arranging all primary, inpatient hospital and long-term care services required by a PACE member Page 12 6

7 Managed Care Options Options if ONLY have Medicare OR Medicaid Insurance Fee for Service Managed Care Model Have MEDICARE only Have MEDICAID only Regular Medicare Original Medicare Part D plan Medigap (optional) Regular Medicaid only for people excluded or exempt from managed care (spend down, transitioning to Managed Care, etc.) Medicare Advantage plan usually covers Part D Voluntary but ~30% of Medicare beneficiaries join Pros: Cheaper than a Medigap premium and controls other out-ofpocket costs Cons: Must be in-network and obtain plan approval Medicaid Managed Care Mandatory for non-dual eligibles Covers primary, acute and long term care HARP Page 13 Managed Care Options Options for Dual Eligibles Insurance Fee for Service Managed Care Model Medicaid & Medicare (dual eligibles) Medicare Original Medicare Part D plan Medigap (optional) Medicaid Medicare Original Medicare Part D plan Medigap (optional) Medicaid Medicaid card only for primary, acute care IF DON T NEED LONG TERM CARE SERVICES Medicaid Advantage voluntary. Combines Medicare Advantage with Medicaid managed care plan in ONE. If in Medicaid Advantage can not join an MLTC. IF NEED LONG TERM CARE SERVICES MLTC Mandatory for most dual eligibles. Primary & acute care thru Medicare, with CHOICE of Original Medicare/Part D or Medicare Advantage plus Medicaid through MLTC Medicaid Advantage Plus (MAP) or PACE or FIDA or FIDA-IDD voluntary option replaces all Medicare, Medicaid and MLTC coverage in ONE plan (full capitation) Page 14 7

8 Medicaid Managed Care NY State July 2016 Managed Care Enrollment MLTC PACE 9 Plans over 12 counties; 5,512 enrollees MLTC Partial Cap 32 Plans over all counties;157,088 enrollees Medicaid Advantage (declining enrollment upstate) o 7 Plans in 35 counties; 3,276 enrollees o 7 Plans in NYC; 5,323 enrollees Medicaid Advantage Plus (increasing enrollment) o 4 Plans in 7 counties; 325 enrollees o 7 Plans in NYC; 5,638 enrollees Page 15 Medicaid Managed Care NY State April 2016 Managed Care Enrollment Mainstream Medicaid Managed Care and NYSOH o 19 plans; 4,436,994 enrollees o HARP (increasing enrollment) o 13 plans; 47,707 enrollees Page 16 8

9 MLTC Partial Capitation Examples July 2016 Elderplan Dutchess 20 Rockland 67 Nassau 246 Suffolk 202 New York 9,937 Sullivan 5 Orange 52 Ulster 5 Putnam 8 Westchester 90 TOTAL 11,132 Page 17 MLTC Partial Capitation Examples July 2016 Guildnet Nassau 1,884 New York 11,994 Suffolk 2,336 Westchester 477 TOTAL 16,691 United HealthCare Albany 44 New York 1,640 Broome 133 Oneida 70 Erie 68 Onondaga 144 Monroe 233 Rockland 32 TOTAL 2,339 Page 18 9

10 MLTC Partial Capitation Examples July 2016 WellCare Albany 47 Rockland 198 Erie 198 Suffolk 41 Nassau 77 Ulster 110 New York 5,480 Westchester 69 Orange 203 TOTAL 6,423 VNA HomeCare Options Albany 129 Onondaga 388 Chautauqua 108 Oswego 81 Erie St Lawrence 98 Fulton 106 Saratoga 100 Jefferson 83 Schenectady 144 Monroe counties (less than 80 each) 827 TOTAL 2,484 Page 19 Medicaid Advantage Plus July 2016 Fidelis ElderPlan Guildnet Health First Albany (39) Montgomery (3) Rensselaer (14) Nassau (16) Westchester (24) NYC (1,059) Nassau (90) Suffolk (91) NYC (477) Nassau (30) NYC (3,809) HealthPlus NYC (2) Senior Whole Plus NYC (126) VNS Choice Plus NYC (109) Schenectady (18) NYC (56) Page 20 10

11 HARP April 2016 Affinity CDPHP Excellus Health Plus Health First HIP IHA ,720 16,070 3, MetroPlus MVP NY Catholic (Fidelis) Today s Option UHC Your Care 8, , , Page 21 Helpful Resources Transition of Nursing Home Populations and Benefits to Medicaid Managed Care January Transition of Nursing Home Populations and Benefits to Medicaid Managed Care Frequently Asked Questions January h_faq_part_a.htm Office of Health Insurance Programs Transition of Nursing Home Benefit and Population into Managed Care February 2015 Implementation g_home_transition_final_policy_paper.pdf Page 22 11

12 Helpful Resources Transition of Nursing Home Populations and Benefits to Medicaid Managed Care Frequently Asked Questions March Transition of Nursing Home Populations and Benefits to Medicaid Managed Care Frequently Asked Questions Part 2 March BFF7257C1CB7/showMeta/0/ Transition of Nursing Home Populations and Benefits to Medicaid Managed Care Frequently Asked Questions March 2015 (Updated) ahagen@bonadio.com Page 23 Helpful Resources Transition of Nursing Home Populations and Benefits to Medicaid Managed Care Frequently Asked Questions October 2015 (Consolidated) urces/nh%20qas% %20consolidated.pdf Transition of Nursing Home Populations and Benefits to Medicaid Managed Care Frequently Asked Questions Revised January jan_rev_nh_transition_faqs.pdf Page 24 12

13 Helpful Resources FIDA Resources: updates, notices, policy documents, outreach and education, FAQs, webinars FIDA Open Questions FAQ April Page 25 Rates Medicare Advantage Negotiated per diem rates or Medicare rate Commercial Plans Negotiated rates o Pay lesser of daily rate or billed UCC rate Medicaid Managed Care Rate 3 year current FFS (benchmark) rate or negotiated rate Must be increased if it falls below current benchmark rate If previously negotiated rate: pay benchmark during transition unless other arrangement is agreed to Page 26 13

14 Rates Medicaid Managed Care Are you working with MLTC s to set future rates? o What is your value? o What value initiatives are they interested in? Page 27 Bed Hold Methodology Medicaid Managed Care Bed hold methodology unless otherwise negotiated, MCO required to follow current Federal/State Medicaid bed hold regulations (CFR and 10YCRR and 18NYCRR 505.9) prior authorization may be required LOA temporary hospitalization / health care professional therapeutic LOA non-hospitalization / health care professional therapeutic Reimbursement Limitations 50% Not to exceed 14 days in any 12 month period 95% Not to exceed 10 days in any 12 month period Must have been resident for at least 30 days and unit to which recipient will return has a vacancy of no more than 5% If plans not paying contact Vallencia Lloyd (Mainstream) vallencia.lloyd@health.ny.gov OR Mark Kissinger (MLTC) mark.kissinger@health.ny.gov Page 28 14

15 Billing / Payment Cycle Medicare Advantage and Commercial Billing cycle monthly Payor specific payment cycle and remittance retrieval options BCBS switch to InstaMed Medicaid Managed Care Billing Cycle at least every 2 weeks (bi-weekly) or twice a month o Not generally mentioned in provider/billing manuals don t make assumptions o Does billing department needs to change current process? Payor specific payment cycle and remittance retrieval options Medicaid Weekly payment cycle Page 29 Maneuver Around Obstacles Page 30 15

16 Strainers Underwater obstacles you get pushed into by the current Page 31 Strainers AKA Enrollment Medicare Advantage and Commercial plans Enrollment changes not limited to open enrollment periods although many changes occur then Families often not good at communicating changes Facilities don t routinely verify coverage Page 32 16

17 Strainers AKA Enrollment New Eligible/Not in a Medicaid MCO Coming from home to NH (long term): Apply for Medicaid following all current regulations, including physician recommendation, PASRR process, Patient Review Instrument (PRI), etc. LDSS has 45 days to complete determination for long term Medicaid eligibility Once approved and any penalty period has elapsed and NAMI amount is identified resident has 60 days to choose an MCO NY Medicaid Choice will assist in education, plan selection and enrollment (in a plan with which the nursing home contracts) Auto enrolled if not select MLTC: No lock-in so enrollment may change Page 33 Strainers AKA Enrollment Enrollment Already Medicaid MCO Enrolled MCO must authorize all long term placements and pay the NH while long term eligibility is being conducted by LDDS NH and MCO assist with submitting documentation to LDDS (send MCO authorization with 3559) Member has 90 days from date long term placement is determined to submit the application for coverage of long term custodial placement to the LDSS LDSS will notify MCO, enrollee and NH o If eligible MCO keeps paying NH and NAMI is collected o If ineligible MCO recoup payment from NH and coordinate safe discharge into the community Page 34 17

18 Strainers AKA Enrollment How do you track open enrollment changes? How will you track initial Medicaid managed care enrollments? How will you track enrollment changes? The provider must check eligibility and enrollment status at the time of service or weekly for NH services for billing purposes FAQ March 2015 Develop policies and procedures and provide staff training Failure to track may result in untimely billing to the correct payor 834 electronic enrollment files or will payor provide a roster? Enhanced communication with families? Page 35 Strainers AKA Admission Authorizations Medicare Advantage and Commercial Authorization is generally required o Revenue Code level or Level of Care Medicaid Managed Care If enrolled in a plan, MCO must authorize all long term care placements and will pay the nursing home while long term eligibility is being conducted by LDSS Authorization is generally required Responsibility for initiating authorization and timing is payor specific Ultimately SNF bears the risk Page 36 18

19 Strainers AKA Authorization Requirements UAS-NY assessment completed by Medicaid MCO required when individual enrolls in a plan and every 6 months thereafter or when significant change in condition occurs in person (per MLTC Policy 16.01: UAS-NY Assessment Requirements) MCO required to compare the UAS-NY assessment needs with the MDS assessments conducted by NH and consider both when authorizing services, equipment and supplies The care plan, MDS, UAS-NY, medical record and input from care management team will provide the MCO with the information needed for authorization of services Although reassessment using UAS-NY is required at above schedule, MCOs may authorize for shorter time periods o daily, several times each week, weekly and monthly Medicaid MCO may require authorization for bed holds Page 37 Strainers AKA Admission Authorizations UAS-NY Considerations MCO is using your data to make authorization decisions o How well are you representing your data and your care? Who is working with payer Case Manager? o One or several employees? o Is the presentation the same by all? UAS-NY and MDS don t cross-walk perfectly o Are you documenting in a manner that supports both sets of requirements? Page 38 19

20 Strainers AKA Authorization Requirements All Managed Care Always verify if an authorization is needed and for what services admissions, routine services, supplies, equipment, etc. o If you perform and bill for x-rays do you need an authorization? Payors may require authorizations for some plans but not others o Specific plan determines authorization requirements Document contact person and telephone numbers for future authorization extensions and reassessments Page 39 Strainers AKA Authorization Requirements All Managed Care When is re-authorization required? What form? Portal or paper? Can current staff handle the increase in work due to Medicaid Managed Care? o Case management vs floor staff vs billing staff vs new position? Coordination between billing and prior authorization staff o When/how/does billing get the authorization number? Page 40 20

21 Sweepers Overhanging obstacles Page 41 Sweepers AKA Audits OMIG Work Plan ALP Resident Care and Needs Goods/Services Included in ALP Rate Base Year Audits Eligibility for Bed Holds Capital Costs MDS (7/1/14 6/30/15 rates) Notice of Rate Changes (Rollovers) Rate Appeals Coordination of Benefits Social ADC MLTC Eligibility Home Health Services, Spend Downs, Medicare Maximization Compliance Program On-Site Review Page 42 21

22 Sweeper AKA Audits Do you have revenue cycle policies and procedures? Include: Admissions, Business Office, Billing, MDS, Therapy, Medical Records, Medical/Professional Services, Nursing, Materials Management o Insurance Verification o Prior Authorizations o MDS Completion/Submission o Therapy documentation/coding/charges o Charge Entry o Consolidated Billing o Claims Submission o Payment Posting o NAMI verification o Resident Trust o Bed Hold o Diagnosis Codes Page 43 Sweepers AKA Audits When were policies and procedures last updated? Software/vendor changes System updates Clearinghouse implemented New positions that changed processes Page 44 22

23 Sweepers AKA Audits Do you have a training program? New hires and routine refresher training o Regular cycle and as needed Must be documented o Staff sign off on skills sheet o Meeting minutes o Attendance sign-in Page 45 Sweepers AKA Audits Do you conduct internal reviews? Credit Balances All payers o Review and process at least monthly for a quick/easy review o Quarterly Medicare Credit Balance Report Denials for all payers o Rotate focus on a new payor throughout the year o Utilize electronic reports Demand Bills requested by resident o Hold self pay billing Medicaid Managed Care Page 46 23

24 Sweepers AKA Insurance Verification Medicare, Medicare Advantage Plan, Medicare Part D, Supplemental Plans, Medigap, Commercial Plans, Medicaid, Medicaid Managed Care, Medicaid Long Term Care, HARP +++ Dual Eligible with original Medicare, Medicare Part D, Medigap and MLTC will have 5 insurance cards Medicaid Managed Care Internal Considerations Provider must check eligibility at the time of service and before billing o Currently may not be checking eligibility before billing Medicaid o Is this going to be a new process? o Will you do it for all payors? o Who is going to do it? o What resources will they use? Page 47 Sweepers AKA Insurance Verification Medicare FISS/Connex Check for each resident not just Medicare Part A admissions Payor websites or phone calls to each insurance Clearinghouse insurance verification portal Batch eligibility verification (271 / 271 files) Prior to billing submit 270 file for eligibility verification via clearinghouse Possible: submit excel spreadsheet to clearinghouse if billing system can t create a 270 file epaces / Plan Rosters Look at eligibility and Restriction/Exemption codes (institutional Medicaid, spend down) Page 48 24

25 Page 49 Sweepers AKA Insurance Verification Avoid being swept into the river Staff training Identify type of coverage (MA, MLTC, Dual Advantage, MAP, etc.) AND plan Document every call/contact in your billing system Complete verification before admission and billing Utilize technology to save time Page 50 25

26 Eddy Water rushes around an obstacle and forms a whirlpool Page 51 Eddy AKA Payor Requirements Revenue Code / Level of Care Billing Rate Claim Format Timely Filing NOMNC Page 52 26

27 Eddy AKA Revenue Code / Level of Care Medicare Advantage and Commercial Billing formats may vary Code properly to get the revenue you are entitled to Revenue Code Excellus Medicare Advantage and Commercial UHC EverCare MVP 191 Skilled Nursing Level I Level A Continuing Care 199 Level Ia 192 Sub-acute Therapy Level II Level B Low Rehab 193 Sub-acute Rehabilitation Level III Intensive Service Delivery Level C High Rehab 194 Level D Medically Complex Page 53 Eddy AKA Revenue Code Medicaid Managed Care Uniform billing codes addressed in budget Law requires standard billing codes by January 1, 2016 Description Fidelis Care at Home Revenue Code Healthfirst Revenue Code Bed Hold Temporary Hospitalization Bed Hold Therapeutic LOA Bed Hold Other Therapeutic LOA 0189 N/A Room and Board + Ancillary Services 0190, 0191, 0192, (all inclusive custodial & respite) Room and Board Only 0190, 0191, 0192, (all inclusive custodial & respite) Page 54 27

28 Eddy AKA Rate What rate should be on claim? Medicare or Medicaid Rate Negotiated Per Diem UCC (Usual and Customary Charge) Watch out for Pays lesser of daily rate or billed UCC rate Page 55 Eddy AKA Claim Format Every new format creates added work Set up like another payor or plan? Which revenue codes? What rate? Which modifiers? Itemized or just R&B? Excluded services? Page 56 28

29 Eddy AKA Claim Format Medicaid Managed Care Claim format may be similar to Medicaid format because rate code is required Claim format may be similar to HMO because authorization number is required Look at each plan and determine if a new claim format needs to be built Requires testing Maintain examples of clean claims for various bill types and service types for each payor and plan in your billing office Page 57 Eddy AKA Timely Filing Know timely filing requirements for each payor Most payors have a 90 day timely filing requirement Contract negotiations may extend this Bill at least monthly no later than the 15 th Bill as often as payor will allow Maximize billing and payment cycle For Example: Medicaid Cycle o Start date = Thursday, 7/7/16 o End date = Wednesday, 7/13/16 o Check date = Monday, 7/18/16 (2 business days after end date) o Check release date = Wednesday, 8/3/16 (3 weeks after end date) Page 58 29

30 Eddy AKA NOMNC Does MLTC payer require a denial from Part A? Results in significant slow down in revenue cycle Will payer accept a NOMNC in lieu of a Part A denial? Develop internal process for issuance of NOMNC Submit copy of NOMNC instead of Part A denial Page 59 Eddy AKA Collections Keep all claims alive with follow up Document every submission, mailing, phone call, etc. No more than days between follow up attempts Verify receipt of claim acceptance reports, fax confirmation, registered mail Utilize billing system collections module o If none write follow up on calendar Prioritize follow up by large dollar and nearing timely filing Group calls to payor to save being on hold Page 60 30

31 Hydraulics Water circulates on top of itself often at the base of a waterfall Can be fatal! Page 61 Hydraulics AKA Denials Per AMA 1.38% 5.07% of claims are denied on 1 st submission Aetna 6.00% UHC 4.30% Cigna 3.80% Medicare 2.30% Need to work electronic rejection/acceptance reports Must review 999 and 277CA o 999 confirms that a file was received. However, the 999 includes additional information about whether the received transaction had errors. Accepted (A), Rejected (R), Accepted with errors (E) o 277CA acknowledges all accepted or rejected claims in the file Must work payor denials review remittances Page 62 31

32 Hydraulics AKA Denials Industry shift toward managed care requires SNF to focus on denial management Denial management is old news to physicians and hospitals Long ago addressed in their billing systems and processes (payment posting and reporting) SNF billing systems and SNF process deficiencies Many billing systems don t capture payment codes Many billing systems can t generate denial management reports Minimal use of clearinghouses and available denial-related reports Many SNFs don t post zero payments Most SNFs do not have a robust denial management program Consider additional report writing add-on software or programming Page 63 Hydraulics AKA Denials Cost to re-work a claim Staff time $10.67 Supplies $ 1.50 Interest $ 1.75 Overhead $ 1.00 TOTAL $14.92 Key Performance Indicators (KPIs): % of denied claims <5% % of EDI denied claims <1% % of paid after 1 st appeal >75% Lag time to work denial < 5 days Page 64 32

33 Hydraulics AKA Retro-Denial Process Win Lose OR Give Up Trying Follow Appeal Process Claim Billed and Paid Records Not Support RUG Payment Retracted Records Requested Track by payor Track documentation deficiencies (make improvements going forward) Learn your weaknesses Therapy minute discrepancy ADL documentation Submit summary page with records that shows how/where RUG/level is supported Perform documentation audit and CDI project Page 65 Hydraulics AKA Appeals Payor and Plan Payor One Payor Two Payor Three MCare and MCaid Advantage Plans Payor Three Medicaid MLTC Appeals/Disputes/Reconsiderations (on-line Provider Manuals) Medical necessity appeal - Submit within 60 days Administrative denial reconsideration (timely filing, co-insurance, eligibility, lacking pre-auth, other errors on claim, underpayments) Submit within 60 days Timely filing penalty of up to 25% may be imposed Timely filing, incidental procedures, bundling, unlisted procedure codes, noncovered, etc. Submit within 6 years of the date of denial Disputes resulting from claim adjustments or denials: Standard reconsideration request denial of payment or medical necessity per contract Disputes resulting from claim adjustments or denials: Standard reconsideration request denial of payment or medical necessity per contract Request for denial of payment due to claim coding Submit within 90 days Request for denial of payment due to no authorization Submit within 90 days Page 66 33

34 Hydraulics AKA Appeals Know each payors appeal process for each type of appeal Filing time limits (60, 90, per contract) Payment discount for timely filing appeal Specific forms Review your process for each type of appeal Who gathers the necessary documents? Who submits? Who monitors status? Are outcomes shared with all? o Are you learning from denied appeals? Page 67 Sandbars Raised area of sand that is easy to get stuck on Page 68 34

35 Sandbars AKA NAMI Collection Estimate at admission and attempt to collect Medicaid Managed Care Initial implementation shifts responsibility to MCO and MCO may delegate it to NH or other entity o Should be outlined/agreed to during contracting o Make sure you have an internal process in place if agreement is different than your current norm o Long term plan State or designee will assume financial and operational responsibility to distribute NAMI and collect NAMI income Page 69 Sandbars AKA NAMI Collection Two important questions Who manages Social Security and other income? Does NH manage a resident fund of PNA money? If NH is rep pay it will never be free from NAMI responsibility Develop a spreadsheet to track $1,000 income Resident = $1,000 Plan collects from resident = $950 Resident give NH $50 PNA (or keep) Plan pay NH $950 $1,000 income NH rep payee = $600 Plan collects from resident = $400 NH keep $50 PNA NH keep $550 of NAMI Plan pay NH $400 Page 70 35

36 Sandbars AKA Self Pay Pre-bill Many NH not pre-bill on new admissions if monthly statements already gone out Need a dedicated collections representative or allocate time for biller to follow up Must make phone calls Extended work hours for collections representative Evenings and Saturday On-site near lobby Be convenient Page 71 Sandbars AKA Resident Fund and Direct Deposit Management Resident Fund Management & Direct Deposit Management Direct Deposit Automated care cost payments and resident allowance retention Direct debits from family member accounts at any bank to pay for care Automatic return of direct deposits when a resident expires or transfers o National Datacare Corporation o Built into some EMR/Billing Systems Page 72 36

37 Thorough Trip Planning Review duties, resources and processes among financial and clinical staff to enhance efficiencies, performance and outcomes Page 73 Assignment of Billing Staff Small homes: one biller may not be enough Current silo structure may become ineffective Medicaid Managed Care o May be too much work for one person to handle o Medicare Advantage/Commercial blurring into Medicaid Managed Care Consider alpha-split or shift additional FTE to Medicaid managed care billing Page 74 37

38 Billing Calendar Make modifications to billing calendar for new billing cycles Page 75 Estimated Per Transaction Opportunity TRANSACTION CLAIM SUBMISSION (837 I /P) Manual Electronic ELIGIBILITY and BENEFIT VERIFICATION (270/271) Manual Electronic PRIOR AUTHORIZATION (278) Manual Electronic CLAIM STATUS (276/277) Manual Electronic ESTIMTED PROVIDER/FACILITY COST $2.58 $0.54 $3.55 $0.16 $18.53 $5.20 $2.25 $0.23 POTENTIAL SAVINGS OPPORTUNITIES $2.04 $3.39 $13.33 $2.02 Page 76 38

39 Estimated Per Transaction Opportunity TRANSACTION CLAIM PAYMENT (835) Manual Electronic REMITTANCE ADVICE (835) Manual Electronic ESTIMTED PROVIDER/FACILITY COST $1.83 $0.30 $1.83 $0.30 POTENTIAL SAVINGS OPPORTUNITIES $1.53 $1.53 Sources: CAQH, Milliman, Inc. (2013) Page 77 Clearinghouse Vendor that serves as a middleman between facility and payors Claims submission: Rather than sending paper claims or electronic claims to each payor as a separate transmission the clearinghouse is a centralized portal that receives your claims and forwards claims to the appropriate payors $2.04 per transaction savings opportunity Many homes use multiple cheap/free which lack in reporting and high-level analysis capability Provides other valuable billing-related services: electronic remittance, eligibility verification, claim status, resident statement printing/mailing, payment portal If use ABILITY for Medicare now (IVANS NOW or EASE) consider CHOICE All-payor Claims and COMPLETE (eligibility) Others may be less expensive with equal or better service don t settle just because ABILITY is what your biller is used to Page 78 39

40 Maximize Billing System Functionality Electronic claims remittance advice and posting If submitting electronically should be able to receive remittances electronically If receive remittances electronically most billing systems can auto-post payments Update file with payors to request electronic remits and request billing system auto-post training...don t assume you know how to do it for each payor o High-value opportunity to eliminate redundancies and errors o $3.06 combined saving opportunity May need a reader if billing system doesn t supply one or request a pdf version of remit from payor Page 79 Maximize Billing System Functionality Batch eligibility verification (271 / 271 files) Prior to billing submit 270 file for eligibility verification via a clearinghouse o May be able to submit an excel spreadsheet to a clearinghouse if billing system can t create a 270 file Fall back plan: utilize payor websites Page 80 40

41 Expect More From Our Systems Common SNF Billing System / EHR Deficiencies Insurance verification Payment code posting o If not posting sequestration reductions will it post VB payment reductions? Need reader for remittances Inadequate reporting and need for additional report writing software o Crystal reports, analytics programs, SQL database programmer Difficulty generating clean claims Difficulty in programming contractual adjustments Account notes and tickler system Lack of sophistication to handle VB arrangements o Bundled payments, hospital readmissions by diagnosis reports, length of stay by diagnosis reports Page 81 Communication Internal Inter-departmental must understand key components of plan and how they impact reimbursement and resident care/ coordination Contract, provider manuals, billing manuals available to all key players Develop summary page of each plan Need to keep updated Page 82 41

42 Clinical Implications Medicaid Managed Care Authorizations/notifications for transfers and other care services (routine, elective, urgent) Clinical staff will have to coordinate with payor case manager for many more residents Significant increase in time Coordination with vendors/suppliers More time required to coordinate coverage and benefits Clinical Appeals More time spent by clinical, HIM, others Documentation changes needed? Page 83 Case Manager Often a Nurse or Social Worker Certification through the Commission for Case Manager Certification (CCMC) or the American Nurses Credentialing Center (ANCC) Function as intermediary between SNF, each resident and the payor balancing the fine line between the discharge goals of the payor, the needs of the resident and working with facility staff to recognize how care delivery changes may be needed to satisfy the discharge requirements of particular payor Monitor expiration, medical record submission dates and approvals of initial, ongoing and ancillary service authorizations Communicate care plan/service changes with payor Page 84 42

43 Page 85 Andrea Hagen, Director Bonadio Receivable Solutions, LLC 171 Sully s Trail Pittsford, NY Office (585) Cell (585) ahagen@bonadio.com 43