Transcript Navigating th

Navigating the Waters of
Health Care Reform and
Keeping your Health Care Plan
Afloat
Jim Williams, Benefit Specialist
Health Plan Pressures
Health
Plan
Provider
Fraud &
Abuse
Fraud & Abuse
30% of all medical bills contain errors
-Stephen Parente, professor of health finance at
the University of Minnesota
Fraud & Abuse
Fraud & Abuse
Fraud & Abuse
Fraud & Abuse
Fraud & Abuse
Health Plan Pressures
Escalating
Costs
Provider
Fraud &
Abuse
Health
Plan
Escalating Costs
Escalating Costs
Escalating Costs
Technological
Advancements
Escalating
Costs
Provider
Fraud &
Abuse
Health
Plan
Technological Advancements
Specialized Radiology
Genetic Testing
Robotics
Rx Costs &
Advancements
Technological
Advancements
Escalating
Costs
Provider
Fraud &
Abuse
Health
Plan
Rx Costs
 In 1990, as a percentage of the
total plan cost-10%
 In 2011, as a percentage of the
total plan cost, this has grown
to 25%
Rx Costs
Contributors to Rx Costs
Double Digit Inflation
Specialty Medications
Sole Source Brand Name Medications
Direct Patient Marketing
• Consumer Choice = Less Cost Effective Choices
• Physician Over Prescribing
Rx Costs &
Advancements
Technological
Advancements
Escalating
Costs
Provider
Fraud &
Abuse
Health
Plan
Over Charging
& Unbundling
Bundled vs. Unbundled Dialysis Claim Comparison
Original
Bundled
Charges
Account #
Dialysis Facility
11/16/10-11/20/10
90999
J1270
J1644
J1756
Q4081
A4657
Patient Name
Item
Charge
Units
Hemodialysis treatment
$5,820.00
3
Hectorol
$1,168.00
12
Heparin
$0.00
24
Venofer
$785.00
100
Epogen
$2,804.25
319
Administration of drug $1,023.75
19
Total
$11,601.00
Client
Rate
$5,820.00
$1,168.00
$0.00
$785.00
$2,804.25
$1,023.75
$11,601.00
AWAC
ARP
Rate
$1,001.17
$51.69
$0.00
$237.36
$436.00
$0.00
$1,726.22
Variance
$4,818.83
$1,116.31
$0.00
$547.64
$2,368.25
$1,023.75
($9,874.78)
H6
1
H6
H6
2
H6
(1) Medical documentaion does not support 6 mcgs of Hectorol.
(2) According to national guidelines recommendations and prescribing information for this drug, dosing of 40,200 units of Epogen,
does not meet dosing and administration guidelines per package insert.
H6 - AWAC Recommended Price
*Note: Please pay to the provider the allowable in the column with the dark box.
Out of Network Claim. Provider would not negotiate. AWAC recommended using ARP (R&C) pricing.
Appropriate billing allowed AWAC to review/recommend coding and billing adjustments as well as
medications that did not meet medical appropriateness.
AWAC
Savings
Rx Costs &
Advancements
Treatment
Protocol
Changes
Technological
Advancements
Escalating
Costs
Provider
Fraud &
Abuse
Over Charging
& Unbundling
Health
Plan
Treatment Protocol Changes
Off-Label Use of Medication
Physician Dispensing
Rx Costs &
Advancements
Treatment
Protocol
Changes
Technological
Advancements
Escalating
Costs
Provider
Fraud &
Abuse
Over Charging
& Unbundling
Health
Plan
Participant
Expectations
Participant Expectations
 100% Coverage
 100% Employer Paid
 No Out of Pocket
Expenses
 Utilize any Physician,
Hospital, or Clinic
 No Pre-Existing
Condition Exclusions
 Enrollment Upon
Demand
Rx Costs &
Advancements
Treatment
Protocol
Changes
Technological
Advancements
Escalating
Costs
Provider
Fraud &
Abuse
Over Charging
& Unbundling
Health
Plan
Participant
Expectations
PPACA
PPACA
 No Pre-Existing Under Age 19
 Children Covered Until Age 26
 Elimination of Lifetime Cap
 Elimination of Annual Cap
 Out of Pocket Expense Cost Sharing
 Deductible Cost Sharing
 Premium Cost Sharing
Communication
Wellness
data
Reporting
PreCertification/Case
Management
data
Keeping Your Health Plan Afloat
Rx
Management
Claims
Administration
Disease
Management
Wellness
Health Risk Assessment
Biometric Screening
Education-Goal Driven
Rewards
• Results
• Participation
 ROI- $1 of Investment = $3 of Return Over 3 Years
Pre-Certification
Case Management
 Early Notification
 Collection of Relevant Information
 Alert Plan to Issues (off label use)
 Initiation of Case Management
 Case Managers
• Professional Accreditation
• Effective Communication w/Plan, Participants, &
Providers
• Aggressive Management & Negotiation
Disease Management
 Patient Focused
 Physician Driven
 At the front of the Health Care Continuum
 Frequent & Direct Communication w/Plan,
Participants, & Providers
 Examples: Cancer, Heart Disease,
Diabetes, etc.
Claims Administration
 Patient Focused
 Effective Use of Technology
• Enhances Access to Information for Patients,
Providers, & Plan
 Low Error Rate
 Prompt Turnaround
 Captures All Claims Data
 Interfaces with all segments of Plan
Rx Management
 Specialty Drugs
• Rx Plan
• Health Plan
• Combination
 Mail Order
 Forcing Generics w/MAC Pricing
 Properly & Precisely Defined AWP
 Personal Communications of Plan Design
to Participants
 Assist Individual Participants w/ Prescription Choices
including Physician Communication
 Data…Data…Data
Reporting
“ If you don’t know how you are spending your
Health Care dollars, you CANNOT properly and
effectively manage and contain your costs. ”
“ He who controls the data controls the plan. ”
Communication
 “ A well designed plan that is not properly
utilized by the participants will not operate
efficiently and economically for anyone. ”
 Participants must understand the plan and
how to use it
 Must be often and consistent
 Must include participants and providers
 60 day prior notice of changes
Summary
Whether you are fully insured or self-funded, you
should have these components as a part of your Health
Plan.
Self funding allows the Plan Sponsor more
flexibility in the design of benefits and selection of
management tools.
Be Aggressive-Make your Benefits Consultant ,TPA
or Agent, work for their pay.
Health Care Reform, PPACA or by whatever name
you know it by, is only a threat to the operation of your
Health Plan if you allow it.
Your Benefit Consultant, TPA, or Agent does not
have all the answers, however, together with an involved
and informed Plan Sponsor, you can maintain a cost
effective Health Plan that provides quality benefits to its
participants.
P.O. Box 1688
Pascagoula, MS 39568-1688
(228) 762-2500 Phone
(800) 530-7222 Toll Free
(228) 769-0401 Fax