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Legal and Insurance Changes Affecting Healthcare Providers W-9 Purpose of this Presentation The goal of this presentation is to educate health care professionals within the mental health and substance abuse community about Facts about treatment nationwide Insurance and in Particular Utilization Review and Problems How new Laws and Regulations are affecting patient care Scenarios and Resources to fight regulatory changes ASAM Disclosures Relevant Financial Relationships Content of Activity: Name Commercial Interests Anelia Shaheed General Counsel Relevant Financial Relationships: What Was Received Relevant Financial Relationships: For What Role No Relevant Financial Relationships with Any Commercial Interests Employee of MedPro Billing No separate payment or funding was received for this presentation The viewpoints here do not represent attorney representations and No attorney client privilege attaches Treatment in America Common Statistics About Health Care Coverage Facility Operation—March 31, 20111 • • • • • • 1 Private non-profit organizations operated 57 percent of all facilities and were treating 53 percent of all clients. Private for-profit organizations operated 31 percent of all facilities and were treating 32 percent of all clients. Local governments operated 5 percent of all facilities and were treating 6 percent of all clients. State governments operated 3 percent of all facilities and were treating 3 percent of all clients. The Federal government operated 3 percent of all facilities and was treating 4 percent of all clients. Tribal governments operated 2 percent of all facilities and were treating 2 percent of all clients http://www.samhsa.gov/data/DASIS/2k11nssats/NSSATS2011Hi.htm Treatment in America Common Statistics About Health Care Coverage Patients In Treatment Among persons in 2011 who received their most recent substance use treatment at a specialty facility, • 46.4 percent reported using their "own savings or earnings" as a source of payment for their most recent specialty treatment, • 38.5 percent reported using private health insurance, • 35.0 percent reported using Medicaid, • 31.2 percent reported using Medicare, • 31.0 percent reported using public assistance other than Medicaid • 26.0 percent reported using funds from family members. http://www.samhsa.gov/data/NSDUH/2k11Results/NSDUHresults2011.htm Projections for Coverage What does 2014 have in store for treatment So how to be prepared… •What do all these changes mean •What is our industry going to do to be prepared and how will I be prepared •I have never taken insurance what do i do now •Will these laws and changes actually do anything to help patients What is Health Insurance? Health Insurance is a form of insurance that provides individuals protection against the cost of medical services Coverage can be privately purchased by individuals, through employers or social welfare programs funded by the government Common Forms of Health Insurance 1 2 Traditional Indemnity or Fee for Service Plans Managed Care Organization/ Preferred Provider Organization (PPO) 3 Managed Care Organization/ Health Maintenance Organization (HMO) 4 Medicare 5 Medicaid 6 Tri-care 7 Federal Program Common Terms Deductible Amount must pay out of own pocket prior to the insurance covering health care cost * Will have caps imposed by ACA Out of Pocket Predetermined total amount of what must be paid prior to coverage paying 100% * Will have caps imposed by ACA Co-insurance Amount must pay for medical care after the deductible has been met. Co-Payment Predetermined flat fee that an individual pays for health care services in addition to what the insurance coverage. Annual/ Lifetime Max. The maximum amount a health insurance plan will pay during the year/lifetime * Will be eliminated by ACA Common Terms Usual and Customary Average contracted rate a carrier has within a specific region or geographical area. *May Be impacted by ACA Cobra Federal legislation that requires employers to offer terminated employees to continue their health insurance coverage for up to 18 months Explanation of Benefits (EOB) Insurance company’s written explanation to a claim showing what was paid and what the client must pay Pre-existing conditions A medical condition that is excluded from coverage by an insurance company because the condition was believed to have existed prior to the individual obtaining insurance coverage *Will be impacted by ACA Government Sponsored Insurance Medicare 1 A federal social insurance program that provides coverage to 1. seniors 65 and older 2. individuals who have end-stage renal disease 3. disabled individuals. Medicare consist of 4 parts. •Part A - refers to Hospital Coverage •Part B - refers to doctors •Part C - coverage through a private health plan (Medicare Advantage) •Part D - relates to pharmacy coverage. Medicaid 2 A federal social insurance program that provides coverage to people of limited income. Federal-State program operated by each state which regulates the qualifications on eligibility and covered services. * Will be expanded under ACA Tri-care and Federal Insurance Tri-Care 1 The armed forces specific health insurance coverage regulated and controlled by the Federal Government. Federal 2 Employees of the Federal Government are insured through BCBS Federal Program. Each local BCBS reimburses payment to providers based on the Federal employee’s benefit. State Exchanges How Insurance Works Determine active coverage and what benefits are available Benefit Verifications. Obtain authorization for care based on medical necessity Utilization Review Submission of claims and follow up for reimbursement Billing and Collections Benefit Verifications • Active Coverage /Effective Date • Pre-existing Condition/ Terms • Deductible and co-pay/ co-insurance • Out of Pocket Maximum • Exclusions and/or Penalties • Pre-cert Company & Phone Number • Claims Address & Phone Number Utilization Review •Obtain Clinicals •Use ASAM Criteria •Contact Managed Care Company •Authorize Services Medical History Mental status Environment . •Concurrent Review Authorization Insurance Carriers & Managed Care Companies Insurance Companies Managed Care Companies Blue Cross and Blue Shield AvMed Humana Aetna Cigna Kaiser United Health Care Magellan Value Options Lifesync Aetna Cigna Behavioral Health Mental Health Network UBH What Changes have happened with Utilization Review Levels of Care Level of Care Problems Possible Remedies Detox Opiate Detox Dual Diagnosis/ Concurrent Medical Condition Inpatient/ Residential Failing Prior Treatment Proper Screening / UA and Vitals Partial Hospitalization Sober Living and Residency Proper Documentation Intensive Outpatient Retroactive appeals / No Cert Policies Proper Documentation Urine Drug Screens Denying for Coding or Medical Necessity Proper Documentation and orders What Changes have happened with Utilization Review Additional Areas of Scrutiny Topic Problems Possible Remedies CARF and JACHO Required for Policy Proper Insurance Verification Licenses Required for Policy / Not issued by the state Proper Documentation that providing service / CARF/ JACHO Licensed Clinical Staff Not having onsite Having proper medical personal supervise Discharge Planning Denying because failing to provide information Begin discharge planning upon admission Doc to Doc and Appeals Requesting more 1st/ 2nd Level Appeals Available Treating Physician and proper medical records What Changes have happened with Utilization Review Additional Areas of Scrutiny Topic Problems Possible Remedies Delays in receiving authorizations Insurance company not immediately responding Requesting preliminary auths prior to admission/ online Issues with continuing care Won’t continue authorizations ACA provisions for longer stays / long term Transferring of patients Patient being transferred from * Don’t do IT!!!! one state to another to continue treatment / or facility What Changes have happened with Utilization Review Medical Records One of the weakest areas where a provider can loose the battle with insurance companies is medical records Always Ensure • • Vitals are Included at All Levels of Care • Proper Physician/ Licensed Clinicians are signing charts • Proper Medications and Disbursements are tracked • Treatment Sessions are documented • Medical Necessity is demonstrated in the notes • Notes are reflective of the dates of service billed and locations billed Treatment follows the level of care and services licensed and being offered • Strong appeal letters and ability to argue medical necessity • Do not disclose anything that is a violation of HIPAA Key Compliance Areas to Meet Medical Criteria • • • • • • • • Fail First Module Treatment co-occuring and continuous Treatment Planning and Discharge Planning Face to Face Assessment, Vitals and Med. Monitoring Not merely following plan Medical Records document treatment Follow up Family Involvement Insurance Criteria You Should Be Familiar With Majority of Insurance Companies Publish Their Criteria Online. Additionally the majority of insurance companies also follow ASAM Criteria Below are links to the Criteria for Substance Abuse and Mental Health • Cigna: • http://www.cignabehavioral.com/web/basicsite/provider/pdf/levelOfCareGuidelines.pdf • UBH/Optum https://www.ubhonline.com/html/guidelines/levelOfCareGuidelines/ • Aetna http://www.aetna.com/plans-services-health-insurance/detail/behavioral-health-insurance/behavioralhealth-benefits.html • Valueoptions http://www.valueoptions.com/providers/Handbook/clinical_criteria.htm Billing & Collections Steps Financial Forms From Patient 1) Obtain Financial forms 2) Submission of claims 3) Follow up of claims 4) Claims payment Claims Claims Submissions Reimbursement Claims Follow Up . How Insurance practices have changed in the industry •Health Insurance Portability and Accountability Act •Mental Health Parity and Addiction Equity Act of 2008 •Affordable Care Act (ACA) •Recent Court Decisions Health Insurance Portability and Accountability Act The Major Points of HIPAA / HITECH Act • Limits Terms of Pre-existing • Establishment of national standards – electronic health care transactions – national identifiers for providers – Safekeeping of information • Requirements for all covered entities and business associates to comply with HIPAA Health Insurance Portability and Accountability Act ***DEADLINE IS SEPTEMBER 23, 2013*** Key Areas of Compliance Compliance Items for Physicians and Business Associates • • • • • • • conducting and documenting a risk analysis, which HHS defines as “an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability” of electronic protected health information (PHI) in your practice; reviewing the practice’s policies and procedures for when PHI is lost or stolen or otherwise improperly disclosed, and making sure your staff members are trained in them; ensuring that the electronic PHI your practice holds is encrypted so that it cannot be accessed if it is lost or stolen (see “Encrypting your patients’ health information”); modifying the practice’s electronic health record (EHR) system so that you can flag information a patient does not want shared with an insurance company; having the ability to send patients their health information in an electronic format; reviewing your contracts with any vendors that have access to your practice’s PHI; and updating your practice’s notice of privacy practices. Health Insurance Portability and Accountability Act Penalties and Fines Mental Health Parity and Addiction Equity Act of 2008 Requires group health plans and health insurance issuers to ensure that financial requirements and treatment limitations applicable to mental health or substance use disorder (MH/SUD) benefits are no more restrictive than the predominant requirements or limitations applied to medical/surgical benefits Medical Benefits SA/MH Benefits Mental Health Parity and Addiction Equity Act of 2008 • • • • • • Mental Health Parity & Addiction Equity Act (MHPAEA) signed into law on Oct. 3, 2008; fully in effect 1/1/2011 MHPAEA applies to employer-sponsored health plans with > 50 employees & Medicaid managed care plans; doesn’t apply to VA or DoD Plans aren’t mandated to offer behavioral health but, if offered, they must do so in a non-discriminatory manner Must provide medical necessity criteria to plan participants & providers upon request If out-of-network benefits covered for medical, out-of-network benefits must be covered for mental health/addiction benefits too Reiterated in ACA provision as applicable to new health insurance benefits and policies States with Parity Statutes Many Individual States Have implemented independent parity requirements that are more restrictive if not in conjunction with the Federal Mental Health and Parity Act. Affordable Care Act • • • • • • • Mental Health and Substance Abuse is mandated as part of the Essential Benefits Package The plan will eliminate annual and life time max Federal supervision on financial standards for insurance companies to spend Federal supervision of plans and programs to meet criteria Individual Mandate to have insurance with penalties Distinction between enrollment for small businesses and large businesses Tax benefits for businesses Important Recent Legal Decisions • Ruled that burden of compliance with parity rested with insurance companies • Pending Class Action Suit involving qualitative restrictions in violation of parity including but not limited to • Qualitative restrictions of utilization review • Retroactive denials • No compliant medical criteria in parity • Non disclosed and not nationally recognized reimbursement methods and allowables Brainstorming … How is Parity and ACA going to Affect Providers 1. Reporting Legal Violations 2. There are not disclosure requirements which require insurance companies to disclose there standards and policies 3. Enforcement is limited and reporting is non-existent 4. Standing and Jurisdiction and enforcement … How will it work. 5. Is reimbursement going to change based on the new plans and federal subsidies 6. Are there enough treatment providers 7. Are insurance companies going to change there restrictive policies How to Protect You and Your Patients Regardless of whether you take insurance or not …. It is important to stay informed and advocate your rights If You Notice a Problem Have your patient contact their •Insurance carrier •Employer •Dept. Of Insurance in their state •Department of HH You as the facility/provider should •Speak with collegues •Contact provider relations •Contact Dept of Insurance in your state Thank You If you would like to obtain a copy of this presentation please email [email protected]