Transcript Health Care Reform Impact: Incorporating the need to directly enroll clients in health insurance and monitor eligibility into a clinic setting Lisa Blanchard, MA Program.

Health Care Reform Impact:
Incorporating the need to directly enroll clients in
health insurance and monitor eligibility into a clinic
setting
Lisa Blanchard, MA
Program Director- Spectrum Health Systems
Margaret Milani
Director of Reimbursement- Spectrum Health Systems
Overview
AIM (Plan)
• Massachusetts Health Care Reform meant access to
health insurance to all member of the commonwealth
• Expanded Medicaid (Masshealth) coverage for children up to 300% of
poverty ($60,000/family of 4)
• Established the Commonwealth Care Health Insurance Program which
provided sliding-scale, subsidized coverage for low income uninsured
individuals and families below 300% of the federal poverty line .
• Beginning in July 2007, all residents required to obtain health coverage if it
is determined that people in their income bracket can afford insurance.
• Programs needed to manage their practice in this
changing environment with less state funded clients and
less self pay= more insured individuals
AIM (Plan)
•
In 2006 prior to health care reform the
payer mix was estimated at
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65% Medicaid
20% State DPH funding for uninsured
10% Third party commercial insured
5% Self Pay
•
In 2010 our current payer mix is
estimated at
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65% Medicaid
10% Commonwealth Care (state supported insurance)
10% State DPH funding for uninsured
12% Third party commercial insured
3% Self Pay
70%
60%
50%
Medicaid
40%
State DPH
30%
3rd party
Self Pay
20%
Commonwealth Care
10%
0%
2006
2010
•Spectrum’s goal was to ensure that our clients were
covered by health insurance and that we ran eligibility to
catch changes and coverage termination as close to daily
as possible (particularly for Opiate Treatment Programs
providing billable services on a daily basis)
CHANGE (Do)
• CHANGE #1: We trained patient account staff on the Massachusetts
Medicaid and Commonwealth Care enrollment system on the online
Virtual Gateway
• This allows staff to directly enroll a client or potential client into a
state supported insurance plan or identify coverage issues (need to
pick a plan or primary care physician, or submit income verification
or update forms) so that we can assist clients with to avoid coverage
problems
• CHANGE #2: We strengthened our insurance verification procedure
to include daily review of insurance eligibility via both running batch
eligibility checks for clients in OTP programs who receive daily
services and individual checks as clients present to appointments
RESULTS (Study)
• Typically assist 25 clients to enroll in insurance or correct
eligibility issues per week
• Many have a minimal or zero copay, which decreases
clients paying for part of their treatment and increases
collections and revenue
• Due to eligibility verification efforts- Process
approximately 60 insurance changes per week in
outpatient
• Proactively catching insurance changes improves the
collection rate of claims submitted
NEXT STEPS (Act)
• Spreading the training for insurance enrollment/virtual
gateway to central intake staff and front desk staff at
smaller locations in order to provide expanded access for
clients to received insurance enrollment assistance
• Utilizing the Virtual Gateway system to assist clients to
receive other types of state assistance (child care, food
stamps, WIC, special services)
• Many clients are required to take employer sponsored
health insurance- but cannot afford premiums- can apply
on VG for premium assistance by the state if within
income level
IMPACT (Business Case, Lessons Learned)
• Difficult to follow this model at smaller clinics with only
one administrative staff
• Increase in 3rd party commercial payers, however many
have poor benefits for substance abuse resulting in high
deductibles, copays and uncovered services, slow claims
processes and cumbersome authorization processes