Transcript Managing your growth in unmanageable time.

Managing your growth in
unmanageable time.
AARON BURKY
DIRECTOR, TRANSITIONAL OPERATIONS
CONIFER HEALTH SOLUTIONS
Agenda Topics
From then until now… growth year over year
Fluctuation in payer practices
Using Key Tools or KPI’s to manage
The hit of a conversion…. What to expect or not expect?
Best Practices in a ever changing world
Brief Case Study
What does the future hold and how can we manage it
From then until now…..
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Managed Medicaid Penetration
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National
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2002 57.5% 23.1MM recipients
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2011 74.2% 42.3MM recipients
2014 and now it looks like this..
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Texas
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2011 70.7% 2.7MM recipients
Steady growth even without ACA
funding Medicaid expansion
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ACA funding Medicaid expansion
in 26 states, with 4 still considering
(20 not considering at this time)
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Federal Government involvement
allows states to offer Medicaid
coverage up to 138% of FPL

Expected to add 4-7MM recipients
in expansion states in 2014 alone
Non-expansion states still
expanding to Medicaid Managed
Care

Value of budget predictibility
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TX—Over 10% of population
expected to be a recipient of
Medicaid Managed Care
Payer changes

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Payer patient plan options
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HMO/PPO/Health Exchange
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Ability to switch plans as much as monthly in some cases
Additional enrollment documents and processing
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Texas—enroll with TMHP first, then with MCO
Payer provider reimbursement changes per plan
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Importance of monitoring appropriate reimbursement
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Government payer—Compliance impact
Understanding of higher number of payers
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Understanding deductibles and POS policies for different payers
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Have to operationalize these differences to be effective
What can we expect and how can we differentiate which plan is chosen?
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Patient advocates—be proactive
Key Performance Indicator
Suggestion
Understand patient mix
 Track and trend all elements of the life cycle of the claim
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Contracting
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Use analytics in negotiations—understand entire organizational performance to
KPIs
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Pre-billing
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Patient Access, coding, billing edits
Post-billing
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What are the causes of not obtaining optimal reimbursement?
Cycle times at payer, denials, underpayments
Post-payment
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Effective methods of post payment audit and review
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Hold payers accountable to contract terms
The hit of a conversion…. What to
expect or not expect?
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What can you expect?
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Dictionary Challenges
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Billing edit variances
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Cash flow sustainability
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DNFB new user training.
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Vendor movement reduction
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Not just benefit of DSH/Nonprofit/Safety-net hospitals, 1/3
drop in 1st qtr 2014 of uninsured at
investor owned systems
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Patient Mix changes
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Higher relative ER volumes—survey
by American College of ER
physicians shows no overall
change in ER volumes, but 35%
increase in Medicaid ER
Best Practices

Trending and Tracking

Clinical nurse

Managed Care/Contracts
involvement

Network with other providers

Know your laws/statutes
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EMTALA—higher ER volumes

Patient Advocacy
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Find Medicaid patients a PCP so
they don’t have to use the ER
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“Safety-net” hospitals that treat a
disproportionate share of poor
and uninsured benefit
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Take advantage of drop in
uninsured and capitalize

Use to offset Medicare cuts
Case Study
How to resolve:

453 Bed Acute Care Facility in KY
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$310MM annual NPSR
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Track and trend
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KY is an expansion state with an
already high Managed Medicaid
penetration rate of 90%

Consistent billing edit review—
engage vendor partners and
leverage their experience
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Disputes
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Legal involvement
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1st quarter 2012
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650 visits/month Managed Medicaid
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286 denials/month
1st quarter 2014
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900 visits/month Managed Medicaid
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820 denials/month
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Specific laws related to ER visits
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Held payer accountable
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Work items in bulk
What does the future hold?
2014
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Large increase of Managed
Medicaid
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Uncertainty in effectiveness of
system
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Vitally important contract
negotiations
Beyond
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ACA picks up the tab for
expansion for 3 years
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What happens next?
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Are we back to current state or is
that long enough to correct
Continued importance of KPIs,
Contracts and Payer performance
monitoring
Thank you
AARON BURKY
CONIFER HEALTH SOLUTIONS
469-803-3875
[email protected]