Transcript CJS Securities 8th Annual New Ideas Summer Conference

ADAP in Crisis:
Cost Recovery Strategies
Presented to the ADAP Advocacy Association
December 5, 2008
About HMS
HMS helps protect the integrity of
government-sponsored health and
human service programs.
Every year, HMS recovers $1 billion for our
clients, and helps them avoid billions more in
erroneous payments.
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Who We Serve
• 43 State clients
• Medicaid
– 36 Medicaid agencies
– 88% of fee-for-service Medicaid population
• Managed Care
– 85 Medicaid managed care plans
– Over 12 million Medicaid lives
• CMS Audit Medicaid Integrity Contractor
• Other Markets
– Child Support agencies
– Veterans Health Administration
– Department of Defense
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More enrollees = more budgetary pressure
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The Opportunity for ADAP
By identifying enrollees with private
insurance, and recovering the cost
of medications, ADAP programs
can make the most of their existing
resources and serve more people
in need.
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Coordination of Benefits
Claim
Patient
Provider
Pharmacy
Payment
State Payor
Medicaid
ADAP
Claim &
Beneficiary
Data
Data from
1000
Insurance
Plans
HMS
PROCESS
$
Carrier
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HMS’s Third Party Identification
and Recovery Capabilities
• Nation’s largest eligibility database
– Over 1,000 insurance plans in data match network
– Continually updated with refreshed data
• Sophisticated data match processes
• Proven recovery processes
– 88% of claims submitted electronically
– Dedicated yield management function
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Case Study: New Jersey
• HMS client since 1985
• More than $1 billion recovered
• Comprehensive service portfolio
– Insurance identification
– Coordination of benefits (COB)
– Near-real time Rx COB
– Financial credit balance reviews
– Clinical reviews
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Case Study:
NJ ADDP Program
• Covers about 6,000 individuals
• Pays 290,000 claims annually
• Maintains relatively open formulary
• Expends $74 million in Rx claims (2007)
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Services for NJ ADDP
• Identification of liable third parties
• Verification of coverage
• Accretion of coverage to State MMIS
• Pharmacy coordination of benefits
• Lockbox services
• Management reporting
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Results for NJ ADDP
• $47.5 million in recoveries since 1995
• $5.8 million in recoveries in 2007
• Where private coverage is identified, all
future claims immediately routed to liable
carrier
• Progressive reduction in payment error
rate
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Opportunities for ADAPs
1. Third party identification and recovery
2. Real-time coordination of benefits
3. Payment accuracy through clinical and
pharmacy audits
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Questions?
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HMS Contacts
Kevin Lee, Regional Vice President
609.588.0471
[email protected]
Lori Karaian, Director of Govt. Relations
704.927.8310 ext. 8225
[email protected]
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