Healthcare Reform Revenue Cycle Impact

Transcription

1 Healthcare Reform Revenue Cycle Impact HFMA First Illinois Chapter May 2012

2 Current Hospital Pressures and Challenges ACO Physician Integration RAC Audits New Payment Models Care Deliveryer Models (Home Care) Mergers & Acquisitions Care Transitions Wellness etc Hospitals 2012 Challenges EHR Implementation Readmissions HAC Quality PPACA PPACA HITECH HITECH 5010 Compliance ICD-10 Migration Firstsource 2012 Confidential May 7,

3 Health Insurance Reform- Overview Early Retirees Plan Pre-Existing Condition Insurance Plan Health Insurance Reform Young People (Under 26) Community Health Centers Firstsource 2012 Confidential May 7,

4 Impacts 2011 Health Reform Bill Provision Year Potential Impact Countermeasures Hospital Payment Reductions 2011 Cumulative reduction 3.4% by 2019 Credit Rating Reduce Costs Year over Year Re-design Care Delivery Focus on cash and bottom-line Targeted philanthropy initiatives Fraud and Abuse 2011 More emphasis on finding fraud Monitor and track RAC and similar and abuse initiatives Adds to an already convoluted Re-design Revenue Cycle systems approach as needed Current programs going after Use expertise to appeal findings recoupment of payments that are not fraud and abuse Overreact and begin to undercharge and undercode Firstsource 2012 Confidential May 7,

5 Impacts 2012 Health Reform Bill Provision Year Potential Impact Countermeasures Health Insurance Exchanges Operated by States 2012 More Choices for Consumer/Patient More Bureaucracy and Payers Unit/Service Payment Will Get Driven Down Opportunity To Develop Local Options Pursue Local Options (Co-op) Reduce Costs Year over Year Streamline Administrative Tasks through Lean standards Geographic Variations Temporary funding for lowest 2012 cost quartile Value Index to be developed Reduce Costs Year over Year Redesign Care Delivery Innovation Center 2012 Pilots and experiments to be funded Large systems likely to receive first funding Monitor for opportunities Develop ideas Firstsource 2012 Confidential May 7,

6 Impact 2013 Health Reform Bill Provision Year Potential Impact Countermeasures Accountable Care Organizations 2013 New Risk Exposure For Populations/Groups Could Lose Patients to Another Health System Could be "Supplier" for Another Health System Explore Capacity to Take Risk Pursue Local Options, Re-design Care Delivery Firstsource 2012 Confidential May 7,

7 Impact 2014 (1/2) Health Reform Bill Provision Year Potential Impact Countermeasures Mandatory health insurance, employer responsibility and coverage expansion 2014 More organized system for patients Increased demand for services Decreased payment to healthcare providers Tax-exempt status t challenges are possible Build Capacity through Lean Structure Reduce Costs Year over Year Improve Patient Satisfaction Re-assess Community Benefit Engage Legislators and other Industry lobby for softening the landing 2014 Shifts patients to lowest payer Build Capacity through Lean Reduce Costs Year over Year Re-design Care Delivery Expansion of Medicaid/Medical id/m Assistance Program May shift some charity care/bad debt up to a payer source Reduction of 2014 Don't currently qualify but we are Monitor status of DSH Disproportionate Share Hospital (DSH) Payments 2014 Don t currently qualify but we are close Monitor status of DSH Bundling Of Services 2014 Five Year Pilot Re-design Care Delivery No known impact Firstsource 2012 Confidential May 7,

8 Impact 2014 (2/2) Health Reform Bill Provision Year Potential Impact Countermeasures No Pay For Readmissions 2014 Re-admissions deemed inappropriate will not be reimbursed by Medicare/Medicaid Monitor Criteria Re-evaluate Care Delivery For Targeted Inpatients Value-Based Purchasing % and 2% bonuses for hitting quality targets Monitor Criteria Re-evaluate Care Delivery For Targeted Inpatients Independent Payment Advisory Board 2014 Binding decisions on Medicare payment Non-binding recommendations for private payers Becomes pseudo single payer system Monitor for Opportunities Firstsource 2012 Confidential May 7,

9 Revenue Cycle Process Patient Access Care Delivery Documentation of Services Billing Receivables Management Customer Service Scheduling Care Delivery Charge Master Claims Editor Payment Posting Customer Inquiries Pre- Registration Case Management Transcription Bill Reconciliation Secondary Billing Issue Resolution Eligibility & Verification Utilization Management Coding/ CDMP Claims Submission Follow-Up Financial Counseling Discharge Planning Charge Capture Contractual Adjustments Appeals/ Denial Mgmt Registration Patient Discharge Late Charges Patient Statements Bad Debt/ Write Offs POS Collection Legal Collections Firstsource 2012 Confidential May 7,

10 Revenue Cycle & Healthcare Reforms Health Insurance Exchanges (HIX Implementation) Medicaid Expansion Payments Changes» Value Based Payments» Bundled Payments» IPAB Cuts» DSH Cuts Payment Integrations» ACO s» Physician Integration. Fraud & Abuse RAC Audits Readmissions Compliance» HIPAA Transactions» ICD 10» Meaningful Use (EHR) Firstsource 2012 Confidential May 7,

11 Medicaid Expansion / Health Insurance exchange (HIX) timeline Pre-existing Conditions Insurance Plans Essential Health Benefit Regulation States to Adopt Legislation States to Implement HIX Qualified Health Plans Exchanges Certification HHS Certification Open Enrollment Ongoing Firstsource 2012 Confidential May 7,

12 Enrollment in an HIX Individual Plan Member Call Center Eligiblity Determination Federal Data Hub validations Medicaid CHIP Members SHOP Employers SHOP Employees Self Service Portal Person Verification Matching, File Clearance Application Tracking Exception Processing (Eligibitlity Fallouts State Referal Tracking Renewal Processing CHIP Enrollment Medicaid Enrollment Navigators Employer Certication Tax Credits Health Plan Type Selection Bronze, Sliver, Gold Navigator validation Brokers , FAX and Paper Process QHP Enrollment Individual enrollment Health Plan Selection Back office processing Rules Maintenance etc SHOP Enrollment QHP Plan Data Firstsource 2012 Confidential May 7,

13 HIX Rules Summary (1/2) Establishment and operation of a HIX by the states» Decide if the HIX will be operated by a non-profit organization established by the state, as an independent public agency, or as part of an existing state agency» A state can also choose to partner with other states on a regional HIX or it can operate multiple HIX that cover distinct geographic distinct areas within the state Participation requirements for health insurance company (i.e. QHPs) that participate in a HIX including, additional standards for health plans offered in an exchange to make sure consumers have access to a variety of providers Decide how a HIX interact with Medicaid agencies when making eligibility determinations» The HIX can conduct complete eligibility determinations for Medicaid or it can make a preliminary assessment and then rely on the state Medicaid agency for a final decision Eligibility determinations to enroll in HIX health plans and in insurance affordability programs Methodology and operational requirements for individual/small group enrollment in QHPs offered thru through a HIX Firstsource 2012 Confidential May 7,

14 HIX Rules Summary (2/2) States to decide on employer eligibility for and participation in the Small Business Health Options Program (SHOP) States to decide if brokers or agents can sell insurance through the HIX States to obtain conditional approval of its HIX by Jan. 1, 2013» Needs to be operationally ready by Oct 1, 2013» HHS will provide additional details in future guidance Firstsource 2012 Confidential May 7,

15 Expanding Coverage under Health Reform Near universal coverage: With Reform by 2019 there would be 92% coverage» Expansion of Medicaid for all to 150% FPL» Subsidies through Health Insurance Exchange for 150% - 400% - FPL» Creation of Insurance Exchanges for the individual and small group markets» Individual mandate» Penalizes employers who don t provide coverage» Elimination of Exclusionary Insurance Practices» Additional enrollment in exchanges through various categories Firstsource 2012 Confidential May 7,

16 Medicaid Expansion Rules (1/2) The creation of four major eligibility groups:» Children, pregnant women, parents and caretaker relatives» A new adult group comprising individuals aged 19 to 64 years old who aren't eligible for Medicare or Medicaid and whose household income is at or below 133% of the federal poverty level ($14,856 for an individual and $30,656 for a family of four) Eligibility determinations:» Establishment t of the modified d adjusted d gross income (MAGI) standard d for determining i financial i eligibility for most Medicaid and CHIP enrollees» Clarifies that people receiving an income-based Medicaid (or CHIP) eligibility determination are not subject to asset tests and cannot be required to complete an in-person interview as part of the application or renewal process» Alignment of various CHIP, Medicaid categories on the requirements of application, submission, verification» Exchange of data electronically from program to program in case of change in circumstances, so that no new fresh application need to be made. Ex: person becoming ineligible for CHIP to Medicaid upon reaching adulthood» Medicaid agencies will be allowed to delegate income-based Medicaid determinations to nongovernmental exchanges, instead of just governmental exchanges as originally proposed» Clarifies Medicaid and CHIP verification standards and requires states to rely primarily on electronic data sources to resolve inconsistencies between the information an applicant or enrollee provides and information available through electronic data matches Firstsource 2012 Confidential May 7,

17 Medicaid Expansion Rules (2/2) Creation of a federal data services hub to link states with federal data sources such as the Social Security Administration and the Department of Homeland Security Accessibility:» Design of a single, online application to allow families to enroll in a coverage program» Medicaid program information must be available on the program website, and it must be available in formats that people with limited English proficiency or disabilities can access Provision of two ways for health insurance exchanges to perform Medicaid- eligibility evaluations» The HIX can conduct complete eligibility determinations for Medicaid, or make a preliminary assessment and then rely on the state Medicaid agency for a final decision A guarantee that the federal government will pay 100% of the cost of the Medicaid expansion for the first three years and at least 90% after that Renewals: Clarifies that states must use a pre-populated Medicaid (or CHIP) renewal form and cannot require enrollees to sign or return the form if there is no change in their circumstances Firstsource 2012 Confidential May 7,

18 Shifting Risk Emerging Payment models New Payment models are evolving, requiring care delivery coordination and risk bearing Degree of Population Risk Transferred to Provider by Payment System Newer Delivery Organizations Low - Risk Shared Financial Risk FFS for Incentives for Quality Scores Bundling of Procedures res and Services FFS with Risk With Holds Fee for Service ery / Coordina ation Emergin ng Care deliv Global Capitation Payment Model Gain Sharing Model (ACO s) Episodic Payments P4P Models (Value based Purchasing, Readmissions Penalty, etc) High - Risk Traditional Delivery Settings Firstsource 2012 Confidential May 7,

19 CMS Targets Readmissions In 2013, CMS will withhold a percentage of Medicare hospital payments for readmissions with greater than expected rates for targeted diagnoses The targeted diagnoses are:» Acute Myocardial Infarction, Heart Failure, Pneumonia Additional Diagnoses to be added in 2015:» Chronic Obstructive Pulmonary Disease (COPD)» Coronary Artery Bypass Graph (CABG)» Percutaneous transluminal coronary Angioplasty (PTCA)» Plus 1 additional vascular condition Penalties: The new healthcare reform law allows CMS to withhold a percentage of inpatient Medicare payments. These percentages will be calculated on a hospital s aggregate Medicare payments for all discharges, not just heart failure, acute myocardial infarction, and pneumonia patients. The impact is as follows:» Up to 1% in FFY 2013» Up to 2% in FFY 2014» Up to 3% in FFY 2015 and thereafter Applies even if the readmission is to another hospital (exceptions apply) Does not apply to critical access hospitals Firstsource 2012 Confidential May 7,

20 Reducing the likelihood of Re-admissions Identify patients at high risk for re-admission Prepare patients for what happens after they leave the hospital Improve communication between patients and members of the heath care team Contact patients post discharge for assessment Assist patient to understand discharge medication orders and medication reconciliation Assure timely access and reduce barriers to follow-up care Evaluate clinical status post-discharge Assess ability to manage self-care Ensure caregiver/support system understands the discharge plan Collaboration occurs with providers to coordinate care in the outpatient setting Create lean processes to close all GAPS and reduce the need for readmissions Firstsource 2012 Confidential May 7,

21 Contact Information John R. Masini Vice President Client Development Ph: Firstsource 2012 Confidential May 7,

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