HMM BillTAG (Billing Transition Action Group)

Transcription

1 Complimentary webinar sponsored by: HMM BillTAG (Billing Transition Action Group) Session 2 Admissions, CMI, FIDA update and FAQ Review May 29, 2015 Presented by: Veronica M. Bencivenga, CPA Director HMM Consulting Office: (631) vbencivenga@horanmm.com 1

2 Today s Agenda To Admit or not to Admit Making a case for the empty bed POP goes the CMI! - Why SNF case mix is rising so fast FIDA - What is it, current enrollment stats and why it does and doesn t work FAQ Greatest Hits 2

3 SNF Perspective SNF transition experience determined by Upstate vs. Downstate Urban vs. Rural Number of plans Size Organizational sophistication 3

4 Your Questions Question Answer If a patient is non Medicaid and LDSS approves the institutional MCD application- who is supposed to reach out to Maximus to advise the patient and the need to select a plan. is it the Nursing Home or LDSS? If we are not effective until July 1, are the benchmark rates for our county published yet? u have emergency transportation excluded from the covered service under MLTC-P col. Do I need to get an authorization for MLTC bed hold? Can you define what the difference between Mainstream Managed Care and MLTC? LDSS notifies Maximus (NY Medicaid Choice) to begin the enrollment process. Family, representative or SNF can assist patient in plan selection. Benchmark rates are published for all Nursing Home Facilities in the state at reimbursement/nhr/ Emergency transportation (ambulance) is covered by Medicare for dual eligibles Generally yes, but you should confirm with the Plan See Slide 37 of today s presentation Are DME and diagnostics(mri,ct scans,xray) excluded from benchmark rate and mltc must precert and pay? It is the same as your Medicaid FFS rate. They are excluded and generally billed to Part B. To ensure proper coverage, you should obtain 4 authorization according to your Plan contract

5 To Admit or not to Admit (Making a case for the empty bed) 5

6 Changing Landscape Global impact of Medicaid Redesign and Medicaid Managed Care on skilled nursing facilities. Consolidation and contraction Lower occupancy Lost revenue Increased competition 6

7 Lower Occupancy Mandatory Medicaid Managed Care in the community Mainstream - effective October 2011 MLTC effective September 2012 Home and Community Based Services (HCBS) Shorter Length of Stay (LOS) in SNF Diversion (Hospital to Home, skip the SNF) Lower Occupancy 7

8 Lower Occupancy Focus on Re-hospitalizations and Potentially Avoidable Hospital (PAH) stays means Fewer patients in the Hospital Fewer discharges to SNF Diversion (Hospital to Home, skip the SNF) Lower Occupancy 8

9 Lower Occupancy SNF (Administration/Owners) knee jerk reaction ADMIT ANYONE 9

10 To Admit or not to Admit What does the empty bed cost? What is the impact on your CMI if the patient stays? Are you ahead if you can t collect the $$$? How many days are we really talking about here? 10

11 To Admit or not to Admit What is filling the bed worth really? 11

12 POP goes the CMI! (Why SNF case mix is rising so FAST) 12

13 Case Mix Rising Mandatory Medicaid Managed Care in the community Mainstream - effective October 2011 MLTC effective September 2012 Home and Community Based Services (HCBS) Shorter Length of Stay (LOS) in SNF Diversion (Hospital to Home, skip the SNF) Higher CMI 13

14 Case Mix Rising Patients coming in are sicker SNF case mix has been artificially deflated by low scoring patients who SNF s couldn t safely discharge 1 PA/PB = 3 RM Source: pdf 14

15 Case Mix Rising Increase in Statewide CMI from Jan 2011 to Jan 2012 of 6%, increasing State spend on SNF by $200 million 5% CMI Cap effective 2013 OMIG audit on increases in CMI greater than 5% SNF s Receive balance over 5% following audit OMIG findings generally support CMI increases 15

16 Case Mix Rising Case Mix MATTERS! SNFs Plans 16

17 Fully Integrated Dual Advantage (FIDA) Demonstration 17

18 FIDA National demonstration project to coordinate benefits for dual eligible individuals (Medicare and Medicaid) requiring chronic care Improve quality Reduce costs Share savings with the States Demonstration runs from January 2015 December 2017 FIDA Demonstration Counties - NYC, Westchester, Nassau, Suffolk only Suffolk roll out on hold Source: /docs/ _fida_stakeholders.pdf

19 Highlights: FIDA Plans are MLTC s that modified offerings to include Medicare services. No change in service level for first 90 days Dual eligible residents in nursing homes are eligible for the demonstration Conversion-in-place Beneficiaries can opt out of the demonstration at any time New Duals will be enrolled in FIDA If opt out, must join an MLTCP and FFS Medicare plan (FFS Medicaid not an option)

20 FIDA vs. MLTC - Benefits MLTC Only covers Medicaid long term care services and supports (PCA, Nursing, etc.), dental, vision, and podiatry services Does not affect Medicare coverage Mandatory FIDA Covers all health care services and items, including prescription drugs Provides Medicare and Medicaid benefits No co-payments Optional Passive Enrollment (excludes SNF in-patients prior to effective date) 20

21 FIDA vs. MLTC - Consumer Medicare Entitlement You pay into this Federal Portable - See any provider Medicaid Eligibility Income based Differs by State Network providers FIDA 21

22 FIDA Enrollment 22

23 Nursing Home Transition Resources FAQ - Greatest Hits 23

24 Transition Resources Source: esign/docs/ _nh_transition_rev.pdf Source: health_care/medicaid/red esign/docs/nursing_home _transition_final_policy_p aper.pdf Source: esign/docs/formatted_nh_faq_part_a.pdf 24

25 Transition Resources Source: march_transition_nursing_home_population_benefits_to_mmc_faq.htm Source: 4ADC B1CB66/showMeta/0/ 25

26 FAQ Greatest Hits They are all important! 26

27 Transition Issues Being Worked on by DOH 27

28 Current Issues Bedhold Plans required to cover Bedhold (page 13 of OHIP). If plan not paying, contact Vallencia Lloyd (Mainstream) or Mark Kissinger (MLTC) Vallencia Lloyd - vallencia.lloyd@health.ny.gov Mark Kissinger mark.kissinger@health.ny.gov Discharging Homeless or no place to discharge to (SNF and Plans same concern) SNF/Patient doesn t agree with the Plan Appeal Rights Can current permanent residents be discharged via managed care? YES, but this isn t new NHTD, Money Follows the Person, etc. - Herbie 28

29 Current Issues Medicaid Recertification NYC issues Currently, Plans can t use EDITS electronic submission program used by SNF s so Plans must submit to Managed Care Division, who then transfers to Long Term division for eligibility Causing delays and confusion HRA to provide education on 6/18 DOH NH Transition call Plan needs to submit a demographic change which will make the address be the nursing home so notices are going to the right place. Guiding patients to plans you contract with YES YOU CAN! Plans have restrictions on marketing, facilities aren t marketing 29

30 DOH Responds Uniform Coding effective 1/1/2016 DOH Working on new universal 3559 Rosters Step 1 make current NH Roster electronic via HCS Step 2 Build enhanced Roster to include Managed Care enrollees 30

31 Resources 31

32 DOH Contact Info State Complaint Number for MLTC Problems: (866) DOH Technical Assistance Center (TAC): You can also cc: your to: State Complaint Number for Mainstream (MMCP) Problems: (800) Request Conflict-Free MLTC Assessment: call NY Medicaid Choice at complaints re Conflict-Free - CF.Evaluation.Center@health.ny.gov For MLTC enrollment complaints call NY Medicaid Choice (855) (Advocates line) (888) (Consumers line) mltctac@health.ny.gov ICAN - OMBUDSPROGRAM FOR FIDA & MLTC (844) Website: icannys.org ican@cssny.org Source: 32

33 Transition Resources Source: esign/docs/ _nh_transition_rev.pdf Source: health_care/medicaid/red esign/docs/nursing_home _transition_final_policy_p aper.pdf Source: esign/docs/formatted_nh_faq_part_a.pdf 33

34 Transition Resources Source: march_transition_nursing_home_population_benefits_to_mmc_faq.htm Source: 4ADC B1CB66/showMeta/0/ 34

35 Managed Medicaid Plans MMC Medicaid Managed Care (aka Mainstream) or MLTC Managed Long Term Care Do you qualify for Medicaid? What level/type of health care service do you need? Routine (CHP, FHP) Episodic (Maternity, joint replacement) Chronic (Community based LTSS, Nursing Home) Are you eligible for Medicare (Dual Eligible)? Are you in a FIDA County (NYC, Nassau, Suffolk, Westchester)? 35

36 MLTC Plans By County Select region, then scroll to bottom on page to see county info: Source: h_care/managed_care/mltc/co nsumer_guides/ 36

37 Topics for Remaining Webcasts 37

38 Future Topics 6/19 6/26 7/24 7/31 It s all about DATA Learn what you should be doing to collect it, use it and share it Frenemies Part 1 When SNF s should work together and when they should compete (admissions, billing, discharges) What s in a PLAN Get a look inside how Plans work, how they get paid and what a rate sheet looks like Frenemies Part 2 Why do I need to Partner with Plans, Hospitals and other Providers and how do I do it Comprehensive Review of Managed Care Transition for SNF Uniform Coding effective 1/1/2016 Value Based Purchasing (VBP) What is it and where do SNF s fit in 38

39 Contact Us Have questions, want to suggest a specific topic, or want to review something in greater detail: us at: HMMBillTAG@horanmm.com Please take our 5 question SURVEY 39

40 Thank you. Questions?? 40