Medicare Advantage PFFS Products HFMA 2008 Spring Education Conference Kiet Lam Senior Manager, Triage Consulting Group

Medicare Advantage PFFS Products HFMA 2008 Spring Education Conference Kiet Lam Senior Manager, Triage Consulting Group

In the news Medicare Audits Show Problems in Private Plans NY Times (Oct 2007) Medicare Trend Raises Eyebrows LA Times (Feb 2008) For Recipients of Medicare, the Hard Sell NY Times (Dec 2007)

Agenda Key elements of PFFS products Growth of PFFS Providing care to PFFS members Financial Impact

PFFS definition A PFFS product is an open network Medicare Advantage product offered by a state licensed, risk bearing entity contracted with CMS on an annual basis to provide Medicare benefits

History of PFFS Created by the Balance Budget Act of 1997 (BBA) Expand private options to beneficiaries Extend availability to rural areas Address right-to-life concerns Updated by Medicare Modernization Act of 2003 Congress raised payments to further stimulate growth Payment to PFFS plans per member is 19% higher than for traditional FFS member (MedPAC, 2006)

PFFS payments $800 $700 County Benchmark Plan Bid FFS Cost $680 Plan retains 75% of difference $600 $500 per capita expenditures

Comparing PFFS with MA HMO/PPO plans Plan/Provider Requirements Payer Requirements: Establish and maintain provider networks Conduct baseline health assessment of new enrollees Identify & coordinate care of members with complex/serious conditions Ensure continuity of care and integration of services Conduct utilization review Work with independent quality review organization to conduct plan review Collect and report HEDIS data for quality assurance purposes Provider Requirements: HMO/ PPO yes yes yes yes yes yes Establish written standards for consideration of member input into treatment plan yes no Hours of operations are convenient to members yes no Maintain health records per established standards yes no source: adapted from Alavare Health's analysis of Medicare+Choice FFS Monitoring Review Guide yes PFF S no no no no no no no

PFFS growth - availability Medicare Beneficiaries with Access to PFFS Urban Rural 76% 97% 100% 54% 59% 34% 27% 26% 28% 20% 29% 42% 39% 2001 2002 2003 2004 2005 2006 2007 source: Medicare Health and Prescription Plan Tracker Kaiser Family Foundation

PFFS growth - enrollment PFFS Enrollment by Year 1,400,000 55% 1,200,000 1,000,000 313% 800,000 600,000 400,000 200,000 1584% 24% 6% 98% 308% 0 2000 2001 2002 2003 2004 2005 2006 2007 source: Avalere Health analysis of CMS data, Medicare Managed Care Contract Report

PFFS growth major players PFFS Enrollment by Plan for 2007 Other, 225,537 (17%) Coventry 72,463 (5%) Humana 562,771 (42%) Universal American 100,697 (8%) WellPoint 104,463 (8%) UHC/ PacifiCare 110,915 (8%) BCBS Michigan 150,970 (11%) source: Centers for Medicare and Medicaid Services

What s in a name? Plan Name Aetna Anthem BCBS BCBS Michigan Coventry Harvard Pilgrim Health Net Humana Sterling Life Ins UHC/Secure Universal Healthcare Open Plan Smart Value Medicare Plus Blue Advantra Freedom First Seniority Freedom Gold PearlChoice, Group Medicare PFFS Option 1 Product Name(s) Medicare Direct Any, Any, Any

Providing care to PFFS members key questions/considerations: Do I have to provide care to a PFFS member? only in an emergency If I provide care, what are the financial implications? what are the risks? is there potential gain? Should I provide or continue to provide care to PFFS?

Terms and Conditions (T&C) Key Features of PFFS Terms and Conditions Name and logo of the PFFS product Contact Information - Phone & Address Coverage Determination Procedure Admission Notification Policy Billing Policies and Procedures Reimbursement Policies and Procedures Dispute Resolution/Appeals Policy

T&C comparison Policies & Procedures Humana BCBSM Universal HC Coverage Determination yes Admission Notification required Special Billing Requirements Billing Timeframe NPI required Bill to local BCBS 365 days Reimbursement Payment Timeframe Dispute Resolution Process Per Medicare Per Medicare Per Medicare 30-days or interest per Medicare yes Per Medicare Per Medicare Dispute Resolution Timeframe

Assess patient volume Starts with Patient Access: Do you have a unique plan code for PFFS plans? If yes: run a report of volume by plan code & description If no: sample your Medicare Advantage volume pull up ID cards talk to patient access reps create unique plan codes

Assess patient volume FY2008 Managed-Medicare Volume Plan Code Plan Description Accts Charges AET SENIOR 500 CHOICE 3 $190,238 BLUE CROSS 800 MEDICARE 17 $202,923 $1,186,67 320 Blue Shield Medicare 8 9 330 Blue Shield Medicare 5 $35,856 $1,265,99 900 HEALTHNET SENIOR 20 3 HUMA CHOICE $3,545,64 240 CARE 24 3 NONCONTRACTED $8,138,68 980 MCARE 54 5 NONCONTRACTED 990 MCARE 26 $330,229 NONCONTRACTED 970 MCARE 1 $94,003 SECURE HORIZONS 160 SECURE HMO HORIZONS 26 $1,017,18 $979,248 170 HMO 31 3

Reimbursement considerations Key questions: Are you contracted with the PFFS plan? How do such rates compare to what original Medicare would have paid? Are you satisfied with your Medicare margin? Is there opportunity to negotiate for more?

Reimbursement pitfalls Important to consider: No advance coverage determination required may lead to retroactive denials Lesser of contract or Medicare payment Indirect Medical Education (IME) needs to be billed separately to Medicare IPPS Excluded Services Acute rehab Acute psych SNF

Blue Cross Freedom Blue Established by Blue Cross Life and Health Medicare Advantage PPO California market penetration Key Issue: Does your Blue Cross contract cover the Freedom Blue product? Identifying volume is challenging

Triage recommends Conducting a volume assessment Implementing operational adjustments to better monitor and track patient volume Establishing policies and procedures to ensure payment compliance Considering negotiating PFFS specific rates at a premium above Medicare FFS

Online resources: CMS: http://www.cms.hhs.gov/privatefeeforserviceplan s/ Individual payer websites: Blue Cross: http://www.medicareadv.com/bcc-ca-pffs.html Humana: http://www.humana-medicare.com/medicare-advantageplans.asp BCBS of Michigan: http://www.bcbsm.com/medicare/index.shtml UHC/Secure Horizons: https://www.securehorizons.com/ourplans/maplans.html

Kiet Lam 221 Main Street, Ste 1100 San Francisco, CA Ph: 415-512-9400 kietl@triageconsulting.com