Title: Making Every Dollar Count: Effective Strategies for Using Ryan White CARE Act Funds and Third Party
1Making Every Dollar CountEffective Strategies
for Using Ryan White CARE Act Funds and Third
Party Reimbursement in an Era of Diminished
Resources
2Julia Hidalgo, ScD, MSW, MPHPositive
Outcomes, Inc.Harwood MDwww.positiveoutcomes.ne
tjulia.hidalgo_at_positiveoutcomes.net(443) 203 -
0305
3- Planning Committee
- Aubrey Arnold
- Gayle Corso
- John Eaton
- Theresa Fiano
- William Green
- Deidre Kelly
- Syd McCallister
- AHCA
- Heidi Fox
- HRSA HAB Project Officers
- Johanne Messore
- Yukiko Tani
- TPR Trainers
- Curt Degenfelder
- Marilyn Massick
- Michael Taylor
4Ground Rules
- I do not represent HRSA, CMS, or AHCA
- Let me know if you do not understand
- We can share our feelings at the end of each
section - You will be rewarded for staying awake
- Shut off your electronic devices
- A 15 minute break means 15 minutes!
5Overview of Todays Session
- Overview of financing, third party reimbursement
(TPR), and eligibility determination - Train the trainer approach
- Materials on the POI website
- Please follow-up by email with additional
questions - Topics covered
- HRSAs payer of last resort (PLR) policies
- Changes on the horizon that make it increasingly
important for CARE Act grantees and subgrantees
to address financing and eligibility
determination issues - TPR
- Participating in Florida Medicaid, commercial
insurance, and managed care systems - Estimating your programs costs
- Marketing your programs services
- Eligibility determination
6What is third party reimbursement?
TPR is receiving payment from a source other than
the patient for services provided to patients by
a provider. This other source is the third
party.
7CARE Act Payer of Last Resort Policies
8CARE Act Has Three Principal Fiscal Requirements
- Matching Funds
- Title II Match
- ADAP Match
- ADAP Supplemental Match
- Maintenance of Effort (MOE)
- Payer of Last Resort (PLR)
9Three CARE Act Fiscal Requirements By Title and
Part F
DRP Dental Reimbursement Program
10Title II Matching Fund Requirement
- Introduced in the 1990 CARE Act authorization
- State Title II programs must match a percentage
of Federal funds received under the CARE Act with
State funds or expenditures - Applies only to Title II grantees with gt 1 of
the US AIDS cases reported for the two most
recent fiscal years - The match rate started at 16.66 in 1990 and
increased to 33.33 in 1994 - The required matching fund rate has not been
increased since the CARE Act 1990 authorization - Requirement cannot be waived if a State is unable
to maintain its match rate
11Maintenance of Effort (MOE) Requirement
- Introduced in the 1996 CARE Act reauthorization
- Grantees are required to maintain a level of HIV
expenditures for services at an amount that is
equal to the levels of such expenditures for the
preceding year - The MOE provision under Title I, II, III,
states that the Secretary shall not make a grant
under this subsection if doing so would result in
a reduction of State funding allocated for such
purposes - Federal funding can be decreased but not directly
due to a reduction in other Federal funds,
including reduction in CARE Act funds received by
Title I, II, or AETC grantees
12HAB PLR Policies
- Are CARE Act grantees or sub-grantees required to
bill? - If you provide services that are eligible for TPR
and you charge anyone, you must have a system to
bill and collect from third parties - You must identify potential TPR sources for each
client, refer them for eligibility determination,
set up billing systems, bill all available TPR
sources, and negotiate the best reimbursement
rates possible - While Medicaid eligibility is pending you may use
grant dollars but you must bill retroactively - Pay and chase
- Does HAB support the reduction of a grant award
to their contractors due to increased TPR? - No, HRSA discourages this preferring that you
use the revenue to expand and/or enhance HIV
services
13Who is the payer of last resort (PLR)?
- HAB considers the CARE Act to be the payer of
last resort - Services that must be reimbursed by any private
or public payers should be determined before CARE
Act funds are used to pay for care - It is unclear which CARE Act Title should be
considered the payer of last resort among CARE
Act programs
14HAB PLR Policies
- Must an agency credit their HIV units budget for
TPR or can they retain the funds? - Your organization must report the amount of the
reimbursements to the HIV/AIDS unit and to return
or credit those funds to the HIV program - How can funds received from TPR be used?
- The funds must be used to pay for HIV services to
the populations - Since TP payment is typically less than submitted
charges, should the grantee or contractor bill
for their actual costs? - CARE Act funds cannot be used to balance bill
- Try to negotiate the best possible rate with
insurers
15HAB PLR Policies
- How can our program become a Medicaid provider?
- Check the State Medicaid website or contact the
State Medicaid Program directly - Help can also be obtained from CMSs Regional
Office www.cms.gov/about/regions - Can CARE Act funds be used to pay to prepare to
become a Medicaid provider? - Yes, capacity development funds may be used for
this purpose - The Title I Planning Council must allocate
capacity development funds
16HAB PLR Policies
- What must we do to meet the qualifications to be
a provider if our employees do not meet Medicaid
credential requirements and we provide Medicaid
covered services? - If you do not charge for the covered service or
seek TPR, there is a waiver provision - Otherwise, careful attention should be paid to
staffing a program with quality of care and
reimbursement implications in mind - Your program should evaluate the costs and
benefits of adjusting your staff mix over time to
assess if staffing changes would be beneficial in
the long term to ensure quality of care
17HAB PLR Policies
- Can a grantee require a contractor to become a
Medicaid provider even if the service provided is
not covered by Medicaid? - No
- If a client is enrolled in Medicaid, can CARE Act
funds be used to pay for case management? - If your State Medicaid Plan covers the type of
case management that you provide, Medicaid should
pay for those services - To find out if case management is covered see
www.cms.gov/medicaid/tollfree.asp - To obtain information about your States State
Medicaid Plan see www.cms.gov/medicaid/stateplans
/map/asp - If the case management services provided by your
agency are not covered, then the services may be
paid for using CARE Act funds
18Sliding Fee Scale
- CARE ACT specifies the following sliding fee
scale for clients with an income - lt 100 of FPL may not be charged for service
provided under the grant - gt 100 of FPL must be charged for services based
on a schedule that is available to the public - gt 100 and lt 200 of FPL, the provider will not,
for any calendar year, impose charges in an
amount exceeding 5 of the clients annual gross
income - gt 200 and lt 300 of FPL, the provider will not,
for any calendar year, impose charges in an
amount exceeding 7 of the clients annual gross
income - gt 300 of FPL, the provider will not, for any
calendar year, impose charges in an amount
exceeding 10 of the clients annual gross income
19Sliding Fee Scale
- If a CARE ACT grantee or subgrantee charges for
its services, it must do so on a sliding fee
scale or a schedule available to the public - CARE ACT grantees or subgrantees may use their
discretion, in the case of clients subject to a
charge, to assess the amount of the charge,
including imposing only a nominal charge for the
provision of service - The grantee or subgrantee must take into
consideration the medical expenses of clients in
assessing the amount of the charge
20Challenges to Applying a Sliding Fee Scale
- The ceiling on out-of-pocket payments requires a
high level of documentation of paid bills - Clients have difficulty maintaining records
- Some providers do not have the ability to collect
and account for cash - A problem in small and large institutions
- In large organizations, out-of-pocket payments
are often not applied to the budget of the HIV
program nor does the accounting system separately
identify out-of-pocket revenue generated by the
HIV program
21PLR Policies An Example of Enforcement Challenges
This is a partial list of providers who receive
Title III support from us. I'm sorry, but I
don't feel that I can send you all our referral
providers, as they may or may not know the funds
paying their fees are from Ryan White. It is up
to the patient to disclose to another provider,
and often, that means the provider may chose not
to provide services. This has happened on
numerous occasions, so please understand it would
not be in our patients' best interests to have
you contact all the providers we use. A Title
III Grantee
22PLR Participation in TPR
- Almost all CARE Act medical providers participate
in Medicaid and other payers - Some are locked out of Medicaid managed care
plans who will not contract with them - Some CARE Act providers funded for mental health
and drug treatment services are not licensed and
do not employ licensed supervisors or line staff - Not eligible for participation in Medicaid
- May employ contractors that bill directly with no
revenue returned to the program - Some Medicaid programs have a moratorium on new
provider numbers for certain provider categories - Some CARE Act providers cannot afford
credentialed personnel that would provide
billable services
23PLR Participation in TPR Systems
- Managed care plans have considerable requirements
that CARE Act providers may not meet - 24/7 staffing, HIPAA compliance, staff
credentialing, quality assurance, electronic
claims submission, reporting, risk bearing - Considerable infrastructure investment is
commonly required for HIV providers to become
ready for participation in managed care - Case management and psychosocial support
providers may not provide a billable service - Do provide a billable services but are not
sufficiently credentialed - Some providers may not be aware that they provide
a billable service - Becoming a participating provider is likely to
represent some costs often not covered by CARE
Act capacity building funds
24PLR TPR Issues
- Many CARE Act providers are unaware of their per
unit of service cost - Tend to accept payments that are well below their
actual costs - Commonly have little bargaining power with
insurers - Personnel costs are reported to be rapidly rising
- Unionized organizations are bound by collective
bargaining - Grantee unit cost payments may be less than
program costs - Visits to HIV care providers tend to be
relatively long and labor-intensive - Volume is insufficient to generate increased
marginal revenue - Insolvency is increasing among HIV clinics
- In the past, parent institutions were willing to
support administrative staff and related costs or
absorb uncompensated costs - Many of HIV programs report their institutional
support has eroded rapidly as broader financial
pressures increase - An increasingly hostile environment is reported
25PLR Billing Systems
- Many providers receiving CARE Act funds have
inadequate billing systems - In large systems, their billing systems do not
separately account for HIV program revenues or
expenses - Some staff are not adequately trained,
credentialed, or supervised - Newer or small providers often try to build
rather than buy billing staff capacity - Evidence of coding insufficiency resulting in
lower payments - Do not research and resubmit rejected claims
- CARE Act providers are reluctant to require
payment from self-pay patients - No collections process in place even when
patients have income - Billing systems are not set up to do pay and
chase - Billing software, hardware, and
training/re-training represent significant
operating costs
26PLR Billing Systems
- In some healthcare markets, CARE Act providers
may potentially bill numerous payers - Payers vary in their mechanisms for provider
networks, covered benefits, and the amount that
they will pay - Prior authorization and standing order
requirements must be addressed to ensure payment - Payments may be slow, with claims commonly
rejected at first submission - This level of complexity is quickly outstripping
the capacity of even relatively sophisticated
providers - HIV clinics tend to offer non-covered services
- Prevention, medication education, adherence
counseling
27Can veterans be required to receive services at a
VA medical center?
- In 2004, HAB clarified their policy about
providing CARE Act services to HIV veterans who
are also eligible for VA benefits
http//hab.hrsa.gov/law/0401.htm - CARE Act providers
- May not deny services, including medications to
veterans who are otherwise eligible for the CARE
Act - Should inquire if an individual is a veteran and
enrolled at the VA - Should be knowledgeable about VA medical
benefits, including medications - Must coordinate health care benefits for veterans
28Why do some veterans receive care outside the VA?
- Concerns about quality in the VA system
- Even if enrolled for VA health care, a veteran
does not have to use the VA as their exclusive
health care provider - The VA has limited resources and is funded each
year by Congressional appropriations - The VA encourages veterans to retain existing
health insurance - While veterans cannot be required to seek their
care in the VA, CARE Act programs can provide a
valuable service in making HIV veterans aware of
VA services available procedures for getting VA
care and helping them navigate care systems to
secure HIV care
29What are the eligibility criteria for veterans to
receive services from the VA?
- Eligibility for most veterans health care
veterans is based on active military service in
the Army, Navy, Air Force, Marines, or Coast
Guard (or Merchant Marines during World War II),
and other criteria - VA health care benefits are not just for those
who served in combat or have a service-connected
injury or medical condition - Not all veterans are eligible for VA benefits
- In recent years, VA eligibility requirements have
become increasingly strict
30Can CARE Act grantees or subgrantees contract to
provide services to the VA?
- Yes, individual VA facilities or any of the 21
regional Veterans Integrated Service Networks can
contract with other agencies or groups to provide
care to veterans - Usually, this occurs when a specific service is
not available in the VA system or when providing
the service through a contract is more economical
for the VA - For clinical services, the VA must identify a
need, develop a scope of work, and then obtain
bids for the cost of providing the services
31EFFECTIVE ELIGIBILITY DETERMINATION
32Determination Pieces of the Puzzle
- Vast array of entitlement and discretionary
programs that HIV clients might be eligible for
today and tomorrow - Things change!
- Eligibility criteria (the short list)
- Geographic residency, US citizenship, legal
residency status, age, race (Native Americans),
gender, previous financial contributions by
client, employment, employer, preexisting medical
condition, disability, employability, income,
assets, HIV serostatus, CD4 count, annual or
lifetime utilization of benefits, criminal
convictions - Knowing how to complete the paperwork, document
claims, and making sure clients follow through
33Determination Pieces of the Puzzle
- Disability claims are taking longer than ever to
be processed - Many State and federal entitlement programs have
had layoffs or working with inexperienced staff - SSA HIV policies are under review
- Legal services must be available to pursue claims
- Front-loaded intake and assessment at entry in
care, without re-determination on a regular basis
- There is ineffective communication between care
providers about eligibility triggers - Loss of employment, inpatient admission, change
in clinical condition
34Challenges to Effective Determination
- The Entitlement, Discretionary, and Commercial
System - State and local discretion in the implementation
of federal policy - Lack of coordination of eligibility criteria and
other federal, State, and local policies payer
of last resort - Whose client are you?
- Varying opinions about application of policies
HRSA said - Significant contraction of public benefits due to
the economy, erosion of the tax base, competing
demands, shifts in priorities - Unwillingness of the commercial sector to take
responsibility - Loss of personnel in local and State government
to operate the system - Culture differences between HIV care systems and
entitlement and discretionary systems
35Challenges to Effective Determination
- AIDS Service Organizations and HIV Clinical
Providers - Tend not to maximize resources available in other
systems - Assume that case managers are handling it
- Assume somebody else will take care of
determination rather than coordinating efforts - Often take a passive approach to determination
and do not make the system work for clients
proactively - Take the attitude dont ask, dont tell, giving
the clients the impression that there is a free
lunch - Providers are often unaware that clients are
already enrolled or eligible for care - Do not coordinate applications for benefits
- Flood the system with completed forms to see
what sticks
36Challenges to Effective Determination
- AIDS Service Organizations and HIV Clinical
Providers - Front-load the intake and assessment at entry in
care and do not effectively re-determine clients
on a regular basis - There is ineffective communication between care
providers about eligibility triggers - Loss of employment, inpatient admission, change
in clinical condition - Assume that clients disability claims should
only be HIV-related - Case managers are commonly used to conduct
eligibility determination - Training and retraining of case managers
regarding eligibility determination is often
limited - There are competing demands for their time and
turn-over is growing
37Challenges to Effective Determination
- The Client or Patient
- Many providers assume that the client will be
able to navigate the system - Assume the ability to read and complete forms
- Other providers assume that the client cannot
navigate the system when they can - Determination processes that rely on clients are
commonly doomed - Paperwork is not the highest priority when you
are trying to survive - Clients are commonly not informed that providers
rely on their ability to be paid for their work - Concerns about discrimination and stigma may
result in lack of complete disclosure
38Determination Best Practices
- Collaboration between policymakers to establish
policies and procedures that coordinate benefits - Systematic assessment of the eligibility
determination processes among HIV providers - Centralize intake in EMAs or other jurisdictions
- Review organizational policies and procedures to
determine what is actually being done in your
program to determine clients - Talk to your staff, review insurance status data,
and review client records - Develop continuous quality improvement (CQI) to
improve determination - Identify entitlement and discretionary programs
for which there are barriers to enrollment - Document the problem and establish ongoing
processes for resolution
39Determination Best Practices
- Establish processes to fast track applications
and to train public and commercial claim
assessment staff regarding HIV disease - Routinely monitor changes in entitlement and
discretionary programs that impact eligibility
and adjust accordingly
- Fund and employ trained eligibility determination
workers - Broker roles and responsibilities among medical
providers, case managers, eligibility
determination workers, and legal aid providers to
reduce duplication of effort and maximize
enrollment - Make sure that clients receive the maximum
benefit to which they are legally entitled - Communicate with clients that to continue to
operate, your program must have revenue
40On the horizon
- Deficit Reduction Act
- Proof of Medicaid beneficiaries claiming U.S.
citizenship http//www.cms.hhs.gov/MedicaidEligib
ility/05_ProofofCitizenship.asp - Further Medicaid reforms
- Immigration legislation
41On the horizon
- CARE Act Reauthorization
- Track using Thomas at http//thomas.loc.gov/
- Core service requirements
- 75 of Titles I, II, and III funds must be
allocated to core medical services - HHS shall waive this requirement if there is no
ADAP wait list and core medical services are
available to all HIV individuals - Severity of need adjustment
- Moves to three-tiered Title I funding
- Eliminates double counting by Title I and Title
II - Moves to HIV name reporting as formula funding
basis
42What is the definition of primary medical care?
- Primary Medical Care (HR 5009 and S2339)
- Medication, prescription drugs, diagnostic tests,
visits with physicians and medically credentialed
health care providers, oral health, treatment for
psychiatric conditions, and treatment for other
health care conditions directly related to
HIV/AIDS infection, and health insurance
premiums, co-payments, and deductibles - Does not include case management for non-medical
services or short-term transitional housing
43What is the definition of primary medical care?
- S2823
- Core Medical Services Outpatient and ambulatory
health services, ADAP treatments, AIDS
pharmaceutical assistance, oral health care,
early intervention services, health insurance
premium and cost sharing assistance for
low-income individuals, home health care, hospice
services, home and community-based health
services (except homemaker services), mental
health services, substance abuse outpatient care,
medical case management (including treatment
adherence services) - Support Services A grantee, subject to the
approval of the HHS Secretary, may provide
support services - Such as respite care for individuals with
HIV/AIDS, outreach services, medical
transportation, nutritional counseling,
linguistic services, and referral for health care
and support services for individuals with
HIV/AIDS - Needed to achieve medical outcomes which are
related to the medical outcomes for HIV
individuals
44Florida Medicaid Reform
- Authorized by FL Legislature in May 2005
- Waiver was submitted to CMS in October 2005
- Waiver was approved by CMS in 2005
- Approved by the FL Legislature in December 2005
- Roll out will begin in Duval and Broward
- Enrollment throughout FL by July 2008
45What Florida Medicaid Reform Will Not Do
- Reform will NOT change who receives Medicaid
- Eligibility does not change
- Reform will NOT cut the Medicaid budget
- The budget will continue to grow each year
- Reform is NOT correlated with Medicare Part D
- Florida will NOT limit medically necessary
services for pregnant women - Florida has NOT asked to waive Early and Periodic
Screening Diagnosis and Treatment (EPSDT) for
Children - Children will be able to access all medically
necessary services - Florida will NOT increase beneficiary cost
sharing requirements
46What Florida Medicaid Reform Will Do
- Increase access to appropriate care
- Benefits that better meet recipients needs
- Access to services not traditionally covered by
Medicaid - An opportunity to provide choice and control to
recipients in regard to health care decisions - Ability to earn credit to pay for non-covered
services - Bridge to private insurance
47Key Elements of Medicaid Reform
- New Options/Choice
- Customized Plans
- Opt-Out
- Enhanced Benefits
- Financing
- Premium Based
- Risk-Adjusted Premium
- Comprehensive and Catastrophic Component
- Delivery System
- Coordinated Systems of Care (PSN and HMOs)
- HMOs are capitated
- Provider Service Networks (PSNs) are FFS for up
to three years, then capitated
48What will change with Medicaid reform?
- A roll-out of mandatory enrollment for most
assistance categories (e.g. TANF, SSI), with full
implementation slated for July 2008 - Comprehensive choice counseling by an independent
enrollment broker - Counseling will be provided in person, by phone,
in writing, or through the media, with
Internet-based enrollment offered - Detailed information will be provided to
enrollees - Eligible enrollees must chose a plan
- New enrollees will receive only emergency
services until they enroll or are auto-assigned
to a plan - Enrollment broker must employ a culturally
diverse counseling staff - Florida State University will offer a Choice
Counselor Certificate and develop outreach
materials - Education needs will dramatically change
- Recipients will need to understand differences in
the benefit packages plans offer - Information on opting out of a Medicaid plan will
be provided
49Customized Benefit Packages
- Plans may vary amount, duration, and scope of
certain services for non-pregnant adults - Certain services must be provided at or above
current coverage levels - Other services must be provided to meet
sufficiency standards for the population - Remaining services must be offered, but amount,
scope and duration are flexible - Reform plans can enhance any service above
current levels - Reform plans can add services not currently
covered
50Customized Benefit Packages Required at Least to
Current Limits
- Physician and physician extender services
- Hospital inpatient care
- Emergency care
- EPSDT and other services to children
- Maternity care and other services to pregnant
women - Transplant services
- Medical/drug therapies (chemo, dialysis)
- Family planning
- Outpatient surgery
- Laboratory and radiology
- Transportation (emergent and non-emergent)
- Outpatient mental health services
51Additional Required or New Benefits
- Required for sufficiency
- Hospital outpatient services
- Durable medical equipment
- Home health care
- Prescription drugs
- Required to be offered, but amount, scope and
duration are flexible - Chiropractic care
- Podiatry
- Outpatient therapy
- New or expanded benefits
- Over-the-counter drug benefit from 10-25 per
household, per month - Adult preventative dental, including x-rays,
cleanings, and fillings - Newborn circumcisions
- Acupuncture/medicinal massage
- Additional adult vision lt 125 per year for
upgrades such as scratch resistant lenses - Additional hearing lt 500 per year for upgraded
digital, canal hearing aid - Home delivered meals for a period of time after
surgery, providing nutrition essential for proper
recovery for elderly and disabled
52Medicaid Reform Plans And Networks Broward
Duval
53How will impact of Medicaid reform on HIV
enrollees?
- HIV enrollees must chose a plan
- HIV enrollees identified in Medicaid claims
files may be auto-assigned to a plan agreeing to
provide HIV enhanced benefits or be assigned to a
general plan and have to ask to be move to a plan
with the enhanced HIV benefits ? stay tuned - All plans can access an enhanced capitated
monthly payment that adjusts for the higher cost
of HIV - Protease inhibitors and other HIV medications are
included in the HIV/AIDS capitation rates - Plans will be required to meet HIV access
standards which are being developed now - Home and community-based waiver services will be
carved out of the covered benefits package - PAC Waiver clients can continue to receive their
services through that program - Plans must provide case management directly or by
contract - The HIV disease management program will be phased
out in counties as the Medicaid reform roll-out
is implemented
54Proposed Per Member Per Month Capitated AIDS,
HIV, TANF and SSI Rates Duval and Broward
Rate for TANF female enrollees
55Stay Tuned for New Medicaid Reform Developments
- http//ahca.myflorida.com/Medicaid/medicaid_reform
/
56Capitated And Fee for Service Contracting
57Roles In Commercial Insurance and Managed Care
Systems For CARE Act Grantees And Providers
- Contracting as a network provider
- Forming alliances with plans to provide
grant-funded services through linkage agreements - Advisors regarding program planning, development,
clinical standards and service delivery - Becoming a managed care plan
- Advocacy and monitoring
58Why participate?
- Enhance the quality, accessibility, coordination,
and continuity of care for HIV enrollees - Ensure your agencys ability to access HIV
enrolled in managed care plans so your agency can
offer them grant-funded prevention and
psychosocial services - Improve your agencys likelihood of financial
survival - Diversify your agencys client and income base
- Influence governance and policy making process
within managed care plans - Adopt sound business practices used by managed
care plans to improve your agencys products and
more efficiently use scarce resources
59Why managed care plans may be disinterested in
your agencies participation in their network
- Adverse selection. Attracting members who are
sicker than the general population. - This results in higher than budgeted expenses for
the plan - MCOs may avoid enrolling individuals who are
sicker than the average patient - Some MCOs may avoid enrolling HIV individuals
because of their relatively high treatment cost
60Managed Care Elements
- Combines financing and delivery systems
- Patients receive a defined benefits package
- Patients usually select or are assigned a
primary care provider (PCP) - PCPs act as a gatekeeper who determines access
to specialists, hospital care, and other services - Clearly defines patient populations, modify their
care seeking behavior, and predict their care use
and costs - Identifies and minimizes financial risk while
maximizing profitability - Identifies high risk and high cost patients
- Organizes systems of care that achieve these
goals - Payment is typically paid on a prospective,
capitated basis, but FFS payments may be made
for some services
61MCO Functions
- MARKETING
- MEMBERSHIP ACCOUNTING
- Group billing, contracts, enrollment, and PCP
assignment - NETWORK OPERATIONS
- Provider credentialing and contracts
- MEMBERSHIP SERVICES
- Education and grievances
- CLAIMS ADMINISTRATION
- MIS
- FINANCE
- Budget projections and capitation rates
- UTILIZATION MANAGEMENT AND QUALITY ASSURANCE
62HMO And Other Managed Care Models
- Staff Physicians are HMO employees
- Group Physicians are members of a single or
multi-specialty group practice that contracts
with the HMO - IPA Either the physician contracts directly with
the HMO or through a physician corporation - Network HMO contracts with group practices,
IPA-physician corporations, and/or with
individual physicians - Point of Service (POS) HMO offers members the
option to receive services from non-MCO providers
at a reduced rate of coverage - Preferred Provider Organization (PPO) A system
that contracts with providers at discounted fees
members may seek care from non-participating
providers, but at higher co-pays or deductibles - Integrated Service Network (ISN) A collaboration
of either PCP (horizontal) or primary, specialty,
and inpatient providers (vertical) for managed
care - Physician Hospital Organization (PHO) legal
entity between hospital and physicians to
contract with MCOs
63What is capitation?
- A reimbursement method for health and associated
services in which a provider is paid a fixed
amount - Payment is usually monthly for each member served
- Payments occurs without regard to the actual
number or services provided to the member - Capitation is a
- Means for payment for expected services
- Budgeting tool
- Management tool
- Cost control tool
64Monthly Capitation
Utilization x Cost 12 months x 1,000
members
PMPM
Utilization number of units of service for each
benefit for 1,000 members
Cost average cost per unit of service
PMPM per member per month capitation payment
65Assumptions Underlying Capitation Rate Setting
- Covered and excluded services are clearly defined
- The average utilization rate per service is known
or can be accurately projected - If the average utilization rate varies by
population group, their rates are known or can be
projected - The cost per service is known and is unlikely to
vary during the contract period - Administrative costs are accurately defined
(i.e., there are no hidden costs) and adjustment
can made in the PMPM for those costs - Can additional revenue (i.e., grant income) be
used to supplement the PMPM - Discounts may be taken for efficiency
66Utilization Management
- Prior or pre-authorization (e.g., expensive or
commonly over-used services) - Medical necessity, contracted facility,
cost-effectiveness - Referrals
- Part of gate-keeper function of PCP
- Concurrent reviews
- Is the ongoing service too long and can other
services be substituted? - Formularies
- Open versus closed formularies, generics,
cheapest delivery system - Claims review
- Appropriateness review
- Provider selection and profiling
67Risk Protection Strategies
- Stop Loss / Reinsurance
- Establishes an upper limit on annual health care
costs for an individual member - Aggregate stop loss sets an upper limit for
members - Managed care plans usually purchase reinsurance
- Providers can negotiate stop loss with the plan
- Risk Corridors
- Establishes a ceiling and floor of risk
- Loss greater than the predetermined amount is
reimbursed (e.g., 10 over costs) - Profit greater than the predetermined ceiling is
returned to the plan
68Organizing HIV Services in Managed Care Settings
- Training and experience of clinical staff and
their willingness to treat HIV patients - Ability to rapidly disseminate new therapeutic
approaches and provide on-going training - Contractual relationships with HIV specialists
and social support programs - Up-to-date quality assurance programs
- Attitudes of other patients treated in same
settings and communities in which services are
provided - Adequacy of capitation rate setting system to
cover current and anticipate future HIV costs - Confidentiality, disclosure, and privacy
- Case finding and outreach
- If your organization is negotiating with plans,
make sure that they have considered the unique
clinical needs of your patients!
69Network Standards
- Availability of HIV-experienced PCPs and
specialists - Standing referrals to specialists
- HIV-experienced clinician should be gate-keeper
- Role of HIV-experienced clinician in developing
and implementing care plan - Use of multi-disciplinary teams
- Identifying HIV-experienced clinician to be
responsible for care coordination - Continuity standards for referrals
- Adequacy of network capacity to assure delivery
of covered benefits (e.g., panel sizes) - Accessibility standards
- Travel time, appointment scheduling time, visit
wait time, 24 hour coverage by a real person,
geographic coverage, culturally acceptable
services and providers - Fiscal solvency
70Network Member Selection Criteria Choosing Your
Partners
- Established provider network
- Geographic coverage
- Sufficient capacity and accessible services
- Acceptable marketing, enrollment, grievance, and
disenrollment procedures - Established quality assurance program
- Fiscal solvency
- Established administrative and governance
structure - Meets State licensure criteria
71How can we limit risk in capitation contracting?
- Request risk adjusters in payment (e.g., active
IDUs) - Define precise boundaries between clinic services
and other physicians care, to avoid dumping - Use internal distribution structures which align
individual and group incentives
- Request demographic risk adjusters in payment
- Obtain historical usage data on the population to
be served or from a comparison group - Gain experience with small-scale contracts
- Ensure that adequate termination options exist
- Make sure health plan is a reliable business
partner
72How can we find out which managed care plans
operate in our HIV programs service area?
- COMMERICAL HMOS
- Dually regulated by AHCA and the Department of
Financial Services - AHCA monitors quality of care-related issues
- DFS monitors financial and contractual issues
- To become a commercially licensed HMO, an
organization must receive a health care provider
certificate from AHCA and a certificate of
authority from DFS - A list of plans by county is available at
http//www.floir.com/mc/is_mc_index.htm
- MEDICAID PLANS
- Regulated by the AHCA Bureau of Managed Health
Care - A list of plans is available at
http//www.fdhc.state.fl.us/MCHQ/Managed_Health_Ca
re/MHMO/index.shtml
73Assessing Your Programs Costs
74Several Approaches Are Used to Estimate Unit Cost
- Grant-funded costs Total budgeted amount /
the number of estimated units to be provided - Negotiated payment rates based on documented
direct and indirect costs - Rates based on grantees rate setting
- Relative value units (RVUs)
- RVUs measure the intensity of services based on
the level of skill involved, the duration of the
service, and the facility and overhead support
required - For medical services, we use RVUs from the
Resource Based Relative Value System (RBRVS)
75TACT
- HAB Technical Assistance Costing Tool (TACT) is
designed for clinics and individual medical
providers who want to identify the costs of
delivering health care services to HIV patients - TACT reports provide cost analyses for internal
clinic financial management for third-party
reimbursement - A MS Excel-based software tool with a data-entry
sheet and two printable reports - The design allows users to customize the type of
service categories, define the patient
population, and enter financial and utilization
data on the Input worksheet tab - TACT shows costs as per member per month and per
unit of service for ambulatory, inpatient, and
ancillary services - Find TACT at
- http//www.hrsa.gov/TACT/manual/TactManualTOC.html
76TACT
- TACT calculates and reports costs for each type
of medical care that your clinic provides - The calculations are done two ways
- FFS cost (the estimated cost of one unit of care,
for example an office visit) - Per-member-per-month cost (the estimated cost of
providing all care to one individual during an
average month) - To use TACT, you need to determine
- Annual member months, which is the number of
individuals to whom you provide care times twelve - Annual member utilization of service for each
care type provided, or how much service is
provided - Total annual cost of providing each care type
77Relative Value Units (RVUs) Approach
- RVUs measure the intensity of services based on
the level of skill involved, the duration of the
service, and the facility and overhead support
required - For medical services, RVUs are derived from the
Resource Based Relative Value System (RBRVS) - An RVU scale assigns numerical values to the
intensity of procedures - Example a basic office visit for an existing
patient (CPT code 99211) has an RVU of .56,
which indicates a low intensity of the procedure.
A surgical procedure such as a complicated
nephrectomy (CPT code 50225) has an RVU of 31.79,
indicating the high intensity of the service.
This suggests that the nephrectomy requires
almost 57 times more effort in terms of time,
skill, and resources than a basic office visit.
78Components Of RVUs
- There are three components of medical RVUs
- Work - measures the provider skill and effort
required to complete the service Work RVU for a
99213 .67 - Overhead - measures the overhead resources
required to complete the service Overhead RVU
for a 99213 .69 - Malpractice - measures the malpractice risk
associated with the particular procedure.
Malpractice RVU for a 99213 .03 - Total RVU for a 99213 .67.69.03 1.39
79Evaluating Support Services
- RSM McGlandrey has expanded the use of RVUs to
HIV enabling/supportive services - Example case management, health education,
interpretation, service coordination,
transportation, and volunteer services - This approach can help your program to evaluate a
range of issues associated with the provision of
enabling services, including - What enabling services are being provided?
- What resources are required?
- What can we do with this information?
80Potential Applications
- Utilize Fee Schedule to Negotiate/Evaluate
Reimbursement - Determine if FFS rates offered by payors cover
the costs of providing services - Agencies can either negotiate individually using
their own fee schedule or using a group of
agencies global fee schedule - The global fee schedule developed reflects the
costs of providing services at your agency - Individual fee schedules reflect your program
costs of providing services - Compare the amount of funds awarded by CARE Act
grantees with the cost of providing services - Compare capitation rates proposed by payers with
the cost of providing care
81Potential Applications
- Monitor Patterns of Care
- You can modify the tracking forms to capture
patient information and then use as a basis to
monitor enabling services provided to patients - This would allow you to track the care provided
to patients and ensure that is consistent with
their condition/diagnosis - Use Taxonomy to Track Enabling Services on an
Ongoing Basis - You can input the taxonomy of services into your
MIS to track services provided here forward - This approach allows you to monitor utilization,
consider carving-out grant-funded
programs/services, and seeking separate funding
sources to cover the costs of providing services
82Potential Applications
- Use RVUs to Track Provider Productivity
- RVUs, rather than patient visits, are rapidly
becoming the standard for measuring provider
productivity - This is especially important for HIV/AIDS
providers, where the patients are by definition
of high and varying medical complexity - RVUs for enabling services can be used to measure
the productivity of non-physician staff
83Step 1 Develop standard coding methodology and
Daily Service Tracking Form
- McGlandrey staff with your agency to identify and
define the enabling and medical services
performed by providers - Enabling services were defined at the unit level,
with standard durations and provider types for
all SHN services - A standard coding system was assigned to each
enabling service - A Daily Service Tracking Form is developed for
each provider type, listing the codes and
duration for the services performed by that
specific provider - Each form included blank columns for tracking the
frequencies of service performed and patient ID
number, as well as blank lines for provider name
and date
84Step 2 Perform one-month time study of services
performed
- For a four-week period, front-line staff track
all enabling services performed using the Daily
Service Tracking Form - It is usually necessary to use the form because
MIS do not capture frequency of services
performed - The one-month time study is the minimum length of
time necessary to capture a representative sample
of services - The CPT codes provided during the time study
period are taken from your MIS and combined with
the enabling services provided to form the basis
of the Unit Cost per Service Analysis
85Step 3 Developing RVUs for Enabling Services
- Since enabling services are not assigned a CPT
code, none of the RVU scales, including RBRVS,
have corresponding RVUs - Thus, McGlandrey develops RVUs for the unique
enabling services provided by your agency
86Step 4 Calculating a Cost Factor for each RVU
and a Cost per Service
- Results of the time study are used to calculate a
cost per RVU - Includes both the enabling services tracked using
the Daily Service Tracking Form and services data
your MIS - McGlandrey calculates the cost per RVU by
- Multiplying each service codes frequency by its
RVU to calculate a weighting factor - Adding the weighting factors for all services to
arrive at total RVUs - Dividing the total organizational costs by the
total number of RVUs to derive a cost per RVU - Multiplying cost per RVU by each services RVU to
arrive at a cost per service
87Sample Findings - Service Activity
- On average, about 2.56 enabling services were
provided per patient visit - The distribution of total medical and enabling
services provided to patients during the time
study period is as follows - Number of Services of patients receiving
services - 1-2 51
- 3-5 27
- 6-10 12
- 11-74 9
- The maximum number of enabling RVUs provided to
any one patient during the time period was 35.23 - The cost of providing these enabling services to
this patient was approximately 1,685 - On average, providers performed about 4.2
enabling services per day
88Findings - Service Costs
- A cost schedule is developed by calculating the
average cost per service - Costs for the most frequently performed services
are - Service Description Cost
- 99215 Office/Outpatient visit, est. 129.17
- CT002 Case Report for clinical trial 24.40
- RN001 Nursing triage - telephone 17.22
- CM023 Individual Supervision 46.88
- CM008 Follow-up on entitlement 17.22
- 90782 Injection (SC)/(IM) 5.26
- SS002 Entry to social service organization
17.70 - CM020 Pharmacy refills - nurse 13.87
- 99233 Subsequent Hospital Care 103.33
- CM010 Transportation to Offsite Provider 14.35
89Effective Marketing to Managed Care and
Commercial Insurance Plans
90Developing Your Marketing Plan
- Understand the plans obligation to the Medicaid
Program, employers, or others - Determine their corporate objectives
- Are they looking for cost-effective providers?
- Do they need providers in your geographic area?
- Do they need HIV-experienced providers?
- What has been their attitude toward other
community-based providers? - Do they currently serve HIV/AIDS patients?
- What is their track record?
91Developing Your Marketing Plan
- What is your product?
- How many plan members could benefit from your
product? - Will your product attract new members to the
plan? - How much does your product cost?
- Will the plan have to pay for your product (e.g.,
grant-funded service)? - Are you willing to share some financial risk with
the plan? - What distinguishes your product from that of
another provider? - Will your product enhance the plans network?
- Will your product help meet Medicaids benefits,
network, access, or quality assurance standards?
92Developing Your Strategy
- Form a network of HIV care providers to present a
united front - Minimize unnecessary competition
- Identify effective individuals to negotiate with
plans - Present a positive corporate image
- Minimize negative perceptions of managed care
plans - The costume makes the man
- Prepare marketing materials that present a
positive business image
93What you are selling
- We have experience in
- Delivering clinical services that reflect the
state-of-the art of HIV care - Delivering clinical and psychosocial services to
hard-to- reach populations - Managing behavior to achieve positive clinical
and psychosocial outcomes - Avoiding or reducing psychosocial crises that
reduce adherence to clinical regimens - Delivering culturally sensitive and appropriate
services - Working in an integrated network of clinical and
wraparound services - Delivering cost-effective services through low
overhead
94Example of Effective Marketing Materials
- Prototype materials developed by three integrated
HIV care networks - Central Pennsylvania
- Michigan
- Staten Island/Lower Brooklyn New York
- http//www.gwhealthpolicy.org/cihcn_publications.h
tml
95Effective Management Strategies Improving Your
Bottom Line
96Overview
- Essential functions to expedite payment
- Pre-Visit Activities
- Patient Visit Activities
- Post-Visit Activities
- Management Activities
97Pre-Visit Activities Scheduling Staff
- Allow sufficient time for each visit
- Determine reason(s) for visit (e.g, general
checkup, physical examination, referral,
follow-up) - Remember that new patients consume more
registration, financial counseling, health
records and provider staff time - Collect patient demographic and insurance
information - At minimum, patient name, address, and telephone
number (if any), insurers name (including any
secondary payer(s) and patients insurance
identification number(s) - Verify insurance coverage
- Ensure that coverage extends through visit date
- Determine and secure required pre-authorizations
98Pre-Visit Activities Scheduling Staff
- Determine need for financial counseling
- Inform patient regarding the basic visit fee and
any outstanding balance from prior visit(s) - Instruct uninsured patients to bring
documentation needed to apply for sliding fee
discount - Educate patient regarding your payment policy
- Example payment, including applicable
deductible or co-payment, is expected on date of
service - Establish a payment schedule and monitor patient
adherence - Schedule time with financial counselor, as
necessary
99Pre-Visit Activities Scheduling Staff
- Develop, maintain, and always consult log of
chronic no show patients before assigning
appointment times - Inform negligent patients about their history,
the preparation required for each visit and,
therefore, the importance of either keeping or
calling to cancel appointments - Double book chronic no shows and/or slot them
at the end of the day - Confirm patient appointments, if possible, prior
to visit (e.g., day before) - Re-schedule cancelled appointment slots
immediately
100Patient Visit Activities
- Registration staff should
- Instruct patients to sign-in at registration desk
upon arrival - Pull health record, with attached pre-populated
encounter form or create record for new patient - Number and, as appropriate, complete
pre-populated encounter form - Collect basic visit fee, co-payment or deductible
give patient a receipt for payment - Transport completed encounter form and record to
assigned exam room
101Patient Visit Activities Registration Staf