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1 North Carolina Health Insurance Institute October 10-11, 2013 Greensboro, NC 1

2 What s New With MedCost? We are celebrating 30 years of being in business. 2

3 A New Web Site and Logo 3

4 Enhanced Information on the Web Site 4

5 MedCost Initiatives What We Are Doing Regarding The Changing Landscape In Healthcare Improving Member and Provider Experience Managing Cost of Total Care Improving the Health of Populations 5

6 MedCost Initiatives What We Are Doing Regarding The Changing Landscape In Healthcare We are serving in a role as a trusted advisor on health care reform legislation and changes. Commitment to exceptional and local customer service. Exploring ways to collaborate with providers to meet their needs as we move from pay for volume (Fee for Service) to pay for value. We are working with our partners to ensure compliance for the October 1, 2014 go live for ICD-10. 6

7 MedCost Initiatives What We Are Doing Regarding The Changing Landscape In Healthcare MedCost is moving to an integrated delivery model and exploring options with providers to accommodate the changing landscape. Since January 1, 2013 we have been piloting a Patient-Centered Medical Home model (PCMH) with another health system in Southeastern NC to help reduce readmits and ER visits. Expected trend is that with healthcare reform employers will be looking at self-funded options. 7

8 MedCost Initiatives What We Are Doing Regarding The Changing Landscape In Healthcare We are working with HealtheReports as a pricing Transparency tool to allow patients to compare pricing, quality of care, and see feedback of other members regarding their experience with providers they are considering. An example is shown below for a common procedure for four providers. 8

9 Top 5 Reasons Claims Are Denied By Payer Incorrect member/group information Use information on ID Card. File group # and alternate member # as shown on ID Card. Claims filed on paper rather than EDI Standard practice to file electronically. Many systems require electronic claims for receipt of payment thereby forcing the translation paper to EDI. To validate the integrity of the data, providers should file to MedCost in a standard EDI format through their clearinghouse or practice manager. Claims filed that require additional information Prompt response from provider is expected when a request for additional information is made. Providers should check EOBs to validate they documented the difference between a denial and a request for information. Claims filed with invalid or incorrect diagnosis code or CPT codes Use the most appropriate dx code and CPT code per detail line. Routine wellness visits present challenges and issues could be minimized if appropriate codes are filed. Many dx codes in the V ranges are designed to be a secondary dx and could result in a denial if billed as the primary dx code. Update of patient information for other coverage. Ensure other COB information is included in the electronic claim filing to MedCost. 9

10 ICD-10 Key Facts & MedCost Readiness The October 1 st ICD-10 implementation will accommodate new procedures and diagnosis unaccounted for in the ICD-9 code set and allow for greater specificity of diagnosis-related groups and preventative services. MedCost is prepared for the transition to ICD-10 and will only accept claims for services rendered on or after the implementation date that are coded using ICD-10 codes. MedCost will not accept ICD-10 before the compliance date. Claims are processed based off of the discharge date. MedCost will follow CMS guidelines regarding any claims with dates of service through 9/30/14 being filed with ICD-9 codes. All ICD-10 codes need to be placed on a separate claim with dates of services 10/1/14 and after. 10

11 ICD-10 Getting Ready for ICD-10: MedCost Resources for Providers MedCost ICD-10 Webinar MedCost offers a pre-recorded ICD-10 Webinar for you to view at your convenience. To access, go to our website at click Providers portal, select Provider Education, and click on ICD-10 CM Webinar. Highlights include: An overview of the major differences between ICD-10 and ICD-9. How the transition will impact your practice. The history of ICD-10 and why the industry is moving in this direction. Comparison of present and future coding changes specific to the 122,809 new codes. New formatting and fracture coding features, changes specific to body systems and physician documentation, and the deletion of V-codes. 11

12 Electronic Communications MedCost will continue to update providers via our website and Provider Connection Newsletter If you would like to sign up for electronic communications or provide feedback, please us at 12

13 Inclusive Health Updates Purpose Established the North Carolina Health Insurance Risk Pool in 2007 to provide affordable, individual health insurance coverage to North Carolinians who do not have access to an employer health plan and face higher premiums or who have been denied coverage due to a pre-existing medical condition. Inclusive Health State Option in North Carolina Inclusive Health will end coverage for all State Option Plan members at midnight on December 31, Inclusive Health will continue to process all claims with a date of service prior to January 1, 2014, that are submitted on or before March 31, Inclusive Health Federal Option in North Carolina As of July 1, 2013, Inclusive Health no longer administers the Federal PCIP (Pre-existing Condition Insurance Plan). Members of the Inclusive Health Federal Option Plan were required to change their coverage to a federally administered PCIP plan to continue their risk pool coverage for the remainder of For additional questions or concerns regarding this change, please visit the Inclusive Health website at or call

14 Legislative Updates Health Benefit Exchanges Online insurance marketplace available to individuals & small employers Open Enrollment: Open enrollment began on October 1, 2013 and runs through March 31, 2014 (shorter open enrollment in future years) NC/SC/VA/TN Federally Facilitated Exchange 14

15 Legislative Updates NC Transparency Legislation HB 834 What Does the Legislation Do? Requires providers and DHHS to make available to the public information about the cost of health care. Goal: Improve transparency in health care costs by reporting cost information to the public. What information be submitted to DHHS? Must disclose the following pricing arrangements: Full charges billed to uninsured patients Average negotiated rates with uninsured patients Medicaid reimbursement Medicare reimbursements 5 largest health insurers providing payments on behalf of insureds [NAME OF INSURER WILL BE REDACTED] Applies to the following admissions/procedures: 100 most frequently reported admissions by DRG (identified by DHHS) 20 most frequent imaging/surgical procedures. Who must submit this information? Hospitals & ambulatory surgical facilities When? 100 most frequent admissions by June 30, most frequent imaging/surgical procedures by September 30, 2014 Hospitals will be listed separately and by category. Hospital outpatient & ambulatory surgical facilities listed separately. DHHS tasked with coming up with rules & framework for how this information would be disclosed. Transparency in Health Care Costs. Will not be payer specific. 15

16 Legislative Updates NC Transparency Legislation Other Provisions of HB 834 Charity Policy & Costs (Hospitals & Ambulatory Facilities) Hospitals/facilities must report financial assistance policy & costs Publically available on DHHS website New debt collection requirements examples: Right to request itemized bill Provider must refund undisputed overpayments within 45 days of notice Cannot bill patient for amounts denied by insurance because of untimely filing Tight restrictions on collections activities Must give accurate information regarding network status. Health Information Exchange Established to collect patient demographic and clinical data on all services paid for with Medicaid funds 16

17 Legislative Updates HIPAA Final Omnibus Rule Key Provisions Effective September 23, 2013 Privacy & security rules directly apply to business associates & subcontractors Expands patient right to request/receive copies of PHI Greater ability to restrict sharing of PHI with insurance plans (after payment in full) Modification of breach notification rules Low probability standard New risk assessment New notice of privacy practices requirements New requirements for Business Associate Agreements New limitations on use of PHI in marketing/fundraising New enforcement mechanisms & penalties 17

18 Questions? Thank you for your time today and being a part of MedCost! 18