Correctional Health Care Cost Saving Strategies. July 24, 2014

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1 Correctional Health Care Cost Saving Strategies July 24, 2014

2 Agenda Facility health care issues Medicaid reimbursements Claims administration strategies Preferred provider partnerships Prescription medicine Telemedicine ACA exchange opportunities Next steps Correctional health care expertise Cost-avoidance report 2

3 Today s Presenters: Penny Barron POMCO Group Client Development Executive Jessica Marabella POMCO Group Marketing & Communications Specialist 3

4 Health Care Issues Continually increasing cost to provide adequate prisoner health care (medical, dental and prescription drug) Compounded by the increasing number of inmates, especially those age 55+ High rates of infectious disease, substance abuse, mental illness and other chronic diseases Increase in number of female inmates Compounded by increase in their mental and physical health issues Transportation and/or on-site care costs Especially for facilities in remote/rural locations of some correctional facilities 4

5 5 Medicaid Reimbursements

6 Medicaid Reimbursements Original Medicaid law: most inmates were not able to enroll in or would lose their Medicaid coverage Exception provided in 1997 ACA allows states to expand Medicaid eligibility criteria more incarcerated individuals qualifying for Medicaid coverage Increased reimbursement opportunities for facilities Enroll eligible inmates in Medicaid upon admission to increase reimbursement potential 6

7 Benefits of Medicaid Enrollment Increased reimbursement opportunities for facilities Continued access to health coverage for inmates upon release Continued treatment of mental health and substance abuse illnesses upon release can reduce rates of recidivism 7

8 8 Claims Administration Strategies

9 Claims Administration Partnerships Facilities reviewing and paying claims should seek assistance from a medical claims payment expert such as a third party administrator (TPA) TPAs can assist with unbundling/coding, bill auditing, discount reductions, eligibility and payment TPAs can manage payment of certain surcharges (HCRA) On-site health care provider contracts typically do not include transitional health care services TPAs can offer discharge planning services by nurse case managers 9

10 Utilization Review and Claims Data Analysis UR/UM process to review Treatment Authorization Request (TAR) based on Milliman Guidelines Tracking reporting of emergency room trips and inpatient stays that are emergent in nature Claims data analysis can indicate: Most frequently utilized services by facility Trends in population groups, facilities, or individuals Redundant/unnecessary testing 10 Opportunities for medical management intervention to reduce overall claim costs

11 11 Provider Partnerships

12 Preferred Provider Partnerships Preferred provider contracting guarantees established rates for service Medicare, Medicaid and custom fee schedules Expert TPAs have internal provider services department that manage: Contracting Recruitment Customer service Electronic claim submission and payments 12

13 13 Prescription Management

14 Prescription Medication Management Strategic pharmaceutical provider partnerships offer: Formulary management Ensures use of most clinically effective drugs at lowest costs Competitive medication pricing No return fees or STAT delivery fees Customized Medical Authorization Treatment (MAR) and Treatment Authorization Request (TAR) National pharmacy network 14

15 15 Telemedicine

16 Telemedicine Board-certified physician virtually consults with a patient via an audio or video conference call Ideal for mental health or acute care needs Reduce costs for transportation to external facilities Ideal for rural facilities with limited resources for conveniently located providers Limits the need for 24/hour transportation and urgent care staff on-site 16

17 17 Affordable Care Act (ACA) Exchanges

18 Inmate Eligibility in ACA Exchanges Regulated insurance marketplaces where individuals without employer-sponsored health coverage are able to obtain coverage Opened for enrollment October 2013 Premium credits available for individuals and families with incomes between 133 and 400% of the federal poverty level Enrollment procedures more streamlined than Medicaid 18

19 19 Next Steps

20 Next Steps Identify a partner that can assist with the following: Enroll eligible inmates in Medicaid upon admission Enroll eligible inmates into exchanges upon admission Develop contracts and manage preferred providers Implement a telemedicine strategy Analyze current prescription program and identify opportunities for partnerships that will reduce associated costs Implement a medical management strategy 20

21 Correctional Health Care Expertise Administration of medical and dental claims for both county and privately-owned facilities in four states for over 6,000 beds In-house compliance experts integrated in service delivery team Medical-coding billing experts review and process claims to ensure proper unbundling, eligibility and payment Manage payment of New York State and Massachusetts Public Goods Pool surcharge Established Medicare and Medicaid rate payment and audit procedures Medical Management coordination for catastrophic claimants based on trigger diagnosis Preferred provider contracting for correctional facilities 21

22 Cost Avoidance Report Free custom cost avoidance report analyzing: Fee structures and preferred provider tiers Medicaid and exchange enrollment and other federal reimbursement opportunities Medical management cost avoidance strategies Telemedicine solutions Pharmacy management solutions 22

23 Penny Barron POMCO Group Client Development Executive Jessica Marabella POMCO Group Marketing & Communications Specialist 23 POMCOGroup.com go.pomcogroup.com/blog

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