Presentation to the National COBTPL Conference Jeffrey Cianchetti, M'D', MBA

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Presentation to the National COB/TPL
ConferenceJeffrey Cianchetti, M.D., MBA

• September 29, 2008

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About CareSource

• Non-Profit Managed Care Health Plan
• Serving over 670,000 people
• Medicaid Plans in Ohio and Michigan
• Medicare Advantage Plan - CareSource Advantage
• Administration of the Ohio Childrens Buy-In
  program

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Vision and Mission

• Our VISION is to be an innovative national leader
  in the management of quality public-sector health
  care programs.
• Our MISSION is to make a difference in the lives
  of underserved people by improving their health
  care.

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Financial Approach

• CareSource Financial View
• We are Stewards of the
• Publics Money
• This view drives the balance between providers
  needs, patient clinical needs, and Medicaid
  programs obligation to assure correct payments.

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5 Keys to Financial Success

• Coordination of Benefits (COB)
• Unit Prices (Provider Contracting)
• Claim Logic and Code Edits
• Claim Quality Control
• Medical Management
• Utilization Management
• Quality Management
• Case Management

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Cost Containment
State TPL File
HMS National Eligibility Database
Data Match

• Eligibility
• Paid Claims
• Network Providers
• Known TPL

TPL Master File
Cost Avoidance/Verification
Billing
Disallowance
Subrogation
Claim Audit
DRG Review
Data Analytics
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Cost Containment

• Current CareSource Cost Containment Initiatives
• Coordination of Benefits projects that include
• Cost Avoidance, both Medical and Rx
• Monthly data feeds from vendor/immediate upload
• On-line Revalidation process for quick response
  to provider complaints
• Immediate updates with new information
• Provider Recovery for Medicare and recent claims
  with commercial coverage
• Cycles every 60 days
• Providers have 60 days to review/respond
• Lookback period 12 months (Commercial) or
  Medicare time limits
• Commercial Insurance Billing
• Physician claims and older dates of service ( gt
  12 months)
• Rx claims
• Cycles every month
• Aggressive carrier follow up

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Cost Containment

• Current CareSource Cost Containment Initiatives
  (continued)
• Subrogation for Michigan beneficiaries (Ohio
  retained at State)
• Bill Audit for 100 of large claims (over 100K
  paid)
• DRG Validation
• targeted review to identify potentially
  problematic DRG assignments, then
• medical record review to identify problems
• General Claim Code and Integrity Solution
• Correct Coding Initiative (Medicare)
• National coding standards
• Data analytics to identify overpayments
• Coding errors
• Duplicate claims payments
• Credit Balance Account Recoveries

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Recovery Results
Scope of Projects by Year 2004 Used voluntary
Information received from providers and other
third party coverage received from the
State. 2005 Engaged HMS for retro-recovery
projects that included Commercial Insurance
Billings and Cost Avoidance Policies
2006 Expanded scope of work with HMS to
include Medicare and Commercial Insurance
provider recoupments 2007 Added program
integrity services that included claim review,
medical bill audit, and DRG validation.
Estimated Results
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Future Claim Integrity Goals

• COB/TPL
• Continued improvement of TPL files from the
  states
• Implementation of eValidate for online rapid
  response to provider generated COB information
  inquiries
• Next generation COB Real Time Solution
• Enhanced code edit software solution
• Optimal provider contracting

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Thank You!
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