Transcript Covered California - San Diego

Covered California
Keep calm and keep asking questions
Covered California Health Plans
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
Metal Tier Benefit Levels
• Bronze
• Silver
• Gold
• Platinum
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
HOSPITAL A - Plan ID’s #1 (1 hospital)
Plan Name/INSURANCE NAME
ELIG PYR
Blue Shield PPO
DMD05664
Health Net PPO
DMD12345
Health Net Community Care HMO
DMD23456
Anthem BX EPO
DMD34567
Anthem BX HMO
DMD45678
KAISER HMO
DMD56789
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
Plan ID’s #2 & 3 (Bronze Level Plan ID’s)
PEND PYR
Plan Name/INSURANCE NAME
(Pending elig/premium)
ELIG PYR
Plan Name/INSURANCE NAME (eligible )
IHI070BA
BLUE CROSS EPO-PEND CVD CA
IHI070B1
BLUE CROSS EPO BRZ-CVD CA
IHI070BB
BLUE CROSS HSA -PEND CVD CA
IHI070B2
BLUE CROSS HSA BRZ-CVD CA
IHI186BA
HEALTH NET PPO -PEND CVD CA
IHI186BB
HEALTH NET PPO BRZ-CVD CA
IHI056BA
BLUE SHIELD EPO HSA-PEND CVD CA IHI056B1
BLUE SHIELD HSA BRZ-CVD CA INDEM
IHI056BB
BLUE SHIELD PPO-PEND CVD CA
IHI056B2
BLUE SHIELD PPO BRZ-CVD CA INDEM
IHI217BA
KAISER HMO HSA-PEND CVD CA
IHI217B1
KAISER HMO HSA BRZ-CVD CA INDEM
IHI217BB
KAISER HMO-PEND CVD CA
IHI217B2
KAISER HMO BRZ-CVD CA INDEM
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
HOSPITAL B - Plan ID’s NO PENDING
COVERED CALIFORNIA
ELIG PYR
Plan Name
12345
BLUE CROSS CVD CA
45678
BLUE CROSS ANTHEM
74184
HEALTH NET CVD CA
74185
HEALTH NET PPO
60331
BLUE SHIELD HSA INDEM
60332
BLUE SHIELD PPO
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
HOSPITAL C - Plan ID’s
COVERED CALIFORNIA
Trying to add BLUE CROSS CVD CA
Trying to add Blue shield PPO
ELIG PYR
Plan Name
45678
BLUE CROSS ANTHEM
74185
HEALTH NET PPO
60331
BLUE SHIELD HSA INDEM
60332
BLUE SHIELD PPO
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
Identification
Easy ID?
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
EASY –
CHANGED STANDARD DEFINITIONS!
Anthem BRONZE Card
Basic PPO = Bronze;
Enhanced PPO = Silver
Preferred PPO = Gold; Ultimate PPO = Platinum
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
Blue Shield Eligibility
Enhanced PPO = Silver
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
Health Net – no level listed
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
Covered CA Identification
• Eligibility – IFP does not show icon
• Eligibility systems do not always show Covered CA
benefits
• Health Plan employees do not always know
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
Premium Payments
• Old Methodology – Employer Pays premiums and deducts
employee amount from pay check
• Covered California Methodology – Patient pays premiums,
has 90 days to pay
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
Premium payment methods
• Health Plan – best
• Broker – can cause delay in eligibility
• Covered CA – delay in eligibility
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
Other Complications
• Health plan receives matching federal
funds
• Patients do not have checking accounts –
working on a cash payment process at
stores
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
Eligibility Examples
COVERAGE ELIGIBILITY– month to month
Pt. Discharged – what health plan?
• Jane Kawabunga is admitted on March 31st as Health Net
gold and is verified as covered.
• Jane is discharged on April 2nd and leaves the hospital
before Patient Access can speak to her because the nurses
did not call to say that she was leaving.
• Patient Access checks the eligibility vendor and calls Health
Net but cannot validate April coverage.
• PA cannot talk to Jane because she is staying at her
boyfriend’s and the wrong phone # was entered from the
demog sheet which was difficult to read and not verified.
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
What Health Plan should we use?
1. Health Net Gold
2. Health Net Pending
3. Health Net bronze
4. Private Pay
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
What Health Plan should we use? - Answer
1. Health Net Gold
Leave the original plan ID because the patient was
verified as covered at time of admission.
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
Changes Made
1. Reminder to Reverify benefits on month end
2. Reminder to verify demographics and unclear writing
3. Educate the clinical staff
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
COVERAGE ELIGIBILITY– month to month
– Pt. In-house
• John Kawabunga is admitted on April 30th as Health Net
gold and is verified as covered.
• On May 1st Patient Access checks eligibility vendor and calls
Health Net but cannot validate May coverage.
What do we do?
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
COVERAGE ELIGIBILITY– month to month
– Pt. In-house
• Follow hospital procedure and talk to the patient/family –
avoid letters at bedside
• Verify premium payment or expected payment date
• DOCUMENT discussion with patient/family (name,
relationship, request, outcome)
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
Changes Made
1. Follow up with the patient prior to month end to pay the premium
2. Ask for proof of payment
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
What Health Plan(s) should we use?
• Mortimer Applebush is admitted to Behavioral Health
• Morty (his aka) has Blue Shield/Arta
• We are contracted with Blue Shield/Arta, however,
upon calling to verify coverage, it is found that
Behavioral Health is carved out to MHSA and not
contracted at this facility after providing the facility
tax ID.
• Morty has Medi-Cal secondary.
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
What Health Plan(s) should we use?
1. Blue Shield
2. Blue Shield/Medi-Cal
3. Other Non-Contracted
4. Other Non-Contracted/Medi-Cal
5. Medi-Cal
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
What Health Plan(s) should we use?
4. Other Non-Contracted/Medi-Cal
We will bill Blue Shield because Medi-Cal will deny if
there is other coverage.
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
Other Issues
1. Cancer patients are changed to HMO during
treatment, treatment is stopped until the assigned
HMO can see the patient
2. Non-Contracted Covered California is paying
$500/day, excluding co-pay
3. What else?
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
Business Office
Operations effects
– So far….
Eligibility
• No change seen yet in the eligibility process
• Increased expanded Medi-Cal
• Increased Presumptive Eligibility = increased follow up to ensure Medi-Cal
application completion
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
Actual Account Follow up #1
• 1/1/14 – Pt Admitted, Pt had not received insurance card
• 1/2/14 – Received Ins Info from the patient, called Blue Shield, no record of pt
Pt states premium was paid
• 1/7/14 – Called Blue Shield, obtained benefits:
PPO, no ded; 80%; no mention of Covered CA
• 1/17/14- Received Insurance Card with Covered CA icon
• Jan/Feb – Follow up calls
• 3/3/14 – Cld Ins: Total charges, $39,000, Pmt $2,000;
Pt Liability $15,000
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
Actual Account Follow up #2
•
1/6/14 – Pt Admitted to ED Trauma, pt intubated, rec’d demog info from sister, no ins info
•
1/8/14 – Spouse states Blue Shield Silver, premium paid 1/6, presented BS invoice
•
1/8/14 – Called Blue Shield, no record of patient (daily calls to Blue Shield)
•
1/11/14- Patient expired
•
1/13/14 – Blue Shield gave benefits, cannot pre-cert due to expiration, bill with med rec
•
1/22/14 – billed with med recs and trauma info
•
Feb 2014 – called for status and potential missing information and checked website for
follow up
•
3/5/14 – Blue Shield denied for documentation
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
Health Plan Weirdness
• Medi-Cal AND Covered California Managed Care
• LA Care Mismatched systems
• ?
• ?
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
Low benefits/No explanation
• Patient Admitted with bronze plan in March:
$5,000 deductible, then $500 per day
- Patients AND some counselors do not understand coverage
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
Other Issues
• Increased Patient Anger
• Health Plan confusion as to what is covered
• Incorrect website information regarding contracted
hospitals
• Covered California impacts non-Covered California plans
• Plans won't deny policy based on pre-existing but won’t
pay
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
Surprising Goal
• Increased patient education
• Assist with plan level selection PRIOR to open enrollment
• Education on benefits
• Increased dialog while in house
• Increased physician education
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
Solution
• On-site Financial Patient Advocate
• Helps patients navigate through the proces
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Insurance eligibilty
Sponsored Care
Sort through bills
Redetermination for Medi-Cal
Workers Comp
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
Surprising Goal
• Otani Consulting Group, Inc.
• [email protected]
• (310) 346-1958
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014