Medicaid Management

Stacy Calvaruso, CHAMAssistant Vice President – Patient Management, Ochsner Health System

Congressional Budget Office……

Healthcare Reform is expected to result in Medicaid volumes growing

from 39 Million to 55 Million eligible individuals by 2014

Pro-Active Approaches to upcoming Medicaid Changes

• The Patient Protection and Affordability Care Act (PPACA)

• Medicaid Application Processing• External Vendor• Internal Processes

• Financial Counseling• Patient Profiling• Emergency Department Focus

• Metrics to measure success• Denial Reports• Subsequent Visits

Ochsner Health System• SE Louisiana's largest non-profit, academic, multi-specialty,

healthcare delivery system• Named Consumer Choice for Healthcare in New Orleans for

15 consecutive years• Only Louisiana hospital recognized by U.S. News and World

Report as a "Best Hospital" across seven specialty categories

• 8 hospitals • 38 health centers in Louisiana • 12,500 employees • 850+ physicians in over 90 medical specialties • 300 clinical research trials annually

Commonly known as ‘Obamacare’

•Effective March 2010• Specific provisions to be phased in thru 2020

•Effective April 2010• Medicaid eligibility expanded to include all

individuals and families with incomes up to 133% of the poverty level along with a simplified CHIP enrollment process.

Patient Protection and Affordable Care Act (PPACA)

Patient Management and MEP Unit

Patient Management Division

• Hospital Patient Access Services• Clinic Patient Access Services• Pre-Service Center

• Pre-Registration• Scheduling• Financial Counseling

SWOT - Program Impact• Healthcare Providers should take steps to increase

their understanding of how existing processes may need to be altered in this environment. • Develop multidisciplinary teams that are dedicated to revising key

procedures.

• As a part of overall Healthcare insurance reform programs, there will be a renewed and aggressive nature of reimbursement audits• Close scrutiny of the referral and authorization process. • Many facilities already struggle with this process and Ochsner was

no different.

Overall Objectives• Reduced Authorization and Eligibility Denials

• Ensure consistent financial clearance• Improved POS Collections

• Pre-service patient notification and education• Improved Revenue –

• Fewer delays for Financial Clearance• Decrease Bad Debt Volume – Proactive identification of

options and resources for the patient’s out of pocket liability• 100% screening for Medicaid eligibility• Charity care based on a sliding scale• Prompt pay discounts• Propensity to pay evaluation• No-interest payment plans

2010 Results

Outside Vendor• 6734 Applications• No ED Coverage• No Clinic Coverage• Very limited on-site presence

1 -Medicaid Application Process

Medicaid Application Center

• State Certification for Financial Counselors to accept applications

• 8A – 19P E D coverage• 1 year agreement with new vendor to teach

us how to expand our knowledge • Deep Dive into demographics surrounding

each facility• Extensive work-flow development• Comprehensive training

Financial Counseling – Required!

• Pre-Service Center• Emergency Department• Mobile to Bedside• Clinical Partner • Various Clinics

• Part of treatment team for high $• Walk-in’s

• Open to the Public

Patient Profiling? • Based on data elements

• Age, income, and zip code• Considerations

• Estimated cost of care and patient out of pocket• Propensity to Pay • The likelihood of eligibility for financial assistance

• Financial clearance staff provide “financial informed consent” • patterned after standard pre-surgical informed consent• seeks to educate each patient about coverage benefits• Other options

• 0% Interest Payment Plans• Charity Care, Financial Sponsors, Community Resources, etc.

Prepare for Medicaid Growth

Registration• Eligibility Tool with 270/271 expanded information return • 3rd Party Payor Options

• Victim’s Compensation• Local Charities• Social Security / Disability• COBRA

• Profiling again… Query Medicaid • Medicare primary• Self Pay over 45 yrs old if unemployed

• Inform patients of Medicaid enrollment opportunities• Prioritize screening and enrollment efforts based on expected clinical

outcomes / future needs

The results include approvals, founds coverage and subsequent visits:

Approvals/Founds

•Number/Quantity - 15,246 approvals

•Gross Charges - $57.9 million

•Net Revenue - $13.3 million 

Eligibility Program Results

Number/Quantity - 19,961 visits

Gross Charges - $96.0 million

Net Revenue - $21.4 million

Subsequent Visits

Gross Charges - $153.9 million

Net Revenue - $34.7 million (net expected reimbursement) 

Program Cost - $7.5M (est)

Program Results for FY 2011

• Understand weaknesses in current process

• Prepare for increase in Medicaid administrative paperwork

• Improve communication and accountability

• Reduce Denials

• Reduce YAA’s

• Expand to areas with missing auth related items

2 - Medicaid Auth Task Force

Objectives

Year 1 Reduction of $9M of Gross Charges in denials Year 1 Reduction of $2.37M in YAASavings to organization Year 1 = $2.2MYear 2 = $1.37MYear 3 = $853KTotal = $4.46M

Estimation of 60% reduction in denials over 12 month period in year 1based on Oct-Dec denials received.

Savings reduced by Database & FTE salaries for 2012.

Expected ROI on project

Top10 Denial Reasons

September thru October 2011 Results

Medicaid Denials

Denial Code Description Count Denied AmountCO-16 Claim missing/lacking info 696 $3,931,206CO-38 Services not authorized/provided by designated provider 509 $566,137CO-29 Timely filing 479 $1,268,251CO-31 Patient not identified as insured (Name/# mis-match) 199 $1,446,232CO-197 Pre-Cert / Authorization missing 159 $1,709,220N29 Missing documentation / notes necessary to support claim 129 $225,612CO-22 Coordination of Benefits 87 $101,545CO-119 Benefit Max Reached 81 $55,607CO-140 PCP Authorization Missing/Invalid 66 $309,961N54 Claim / Authorization do not match 65 $936,165

Total 2,470 $10,549,934

Gross charges denial amount

Top10 Denial Reasons

September - October 2011 Results

Medicaid Denials

Denial Code Description Count Denied AmountCO-16 Claim missing/lacking info 696 $3,931,206CO-38 Services not authorized/provided by designated provider 509 $566,137CO-29 Timely filing 479 $1,268,251CO-31 Patient not identified as insured (Name/# mis-match) 199 $1,446,232CO-197 Pre-Cert / Authorization missing 159 $1,709,220N29 Missing documentation / notes necessary to support claim 129 $225,612CO-22 Coordination of Benefits 87 $101,545CO-119 Benefit Max Reached 81 $55,607CO-140 PCP Authorization Missing/Invalid 66 $309,961N54 Claim / Authorization do not match 65 $936,165

Total 2,470 $10,549,934

Gross charges denial amount

CO-140 PCP Authorization Missing/Invalid

CO-197 Pre-Cert Authorization Missing

First Step - Identify who does what

• Pre-Certs

• Refer

rals

• Aut

horization

s• B

enefi

t Verific

ation

• Pre-R

egistra

tion

• Financial Clearanc

e

• Initia

l Payo

r N

otification

• Initia

l Pre-Cer

tificatio

n• B

enefi

t Verific

ation

• Pay

men

t Arra

nge

ments

• Registra

tion

• Refer

rals

• Continue

d Stay R

eviews

• Initia

l Clinicals

• Facilitates

Peer to Peer

• D/C

assist

ance

• Confirms

appropriate stat

us

Pre-Service Center Admit Department Utilization Mgmnt

Lack of Denial data specific to PM areas Lack of automation Documentation in multiple places Inability to know who was assigned to a patient Complex rules and requirements Rotating staff Leadership challenges

Not my job syndrome!

Second Step – Identify root cause?

Lack of Automation, Communication, and Follow-thru

2nd Step - Remove the excuses!!

How should we resolve the issue?

• Use the data to determine what we are doing wrong• Denials• Claim hold volume• YAA’s

• Determine who should ‘own’ the process• Admissions• Utilization Management

• Fix the problem!

Denial Data Review

All Denials received October thru December 2011( Regardless of Admit Date )

TOTAL NON-AUTH & ELIGIBILITY DENIALS

Denial Category Count Dollars

Eligibility 1,768 $5,611,989

Non-Auth/ MCD Non-Covered 88 $539,055

Non-Auth/ No PCP Referral 1,452 $1,384,250

Non-Auth/ Precert 605 $8,786,058

Grand Total 3,913 $16,321,352

Denial Data ReviewAdmit date prior to 10-1-11Denials received in October – December 2011Gross Denial Amount

TOTAL NON-AUTH & ELIGIBILITY DENIALS

Denial Category Count Dollars

Eligibility 1,197 $3,682,139

Non-Auth/ MCD Non-Covered 54 $423,483

Non-Auth/ No PCP Referral 976 $944,164

Non-Auth/ Precert 399 $5,605,116

Grand Total 2,626 $10,654,903

Team Resources

Map out current flow Include key stake holders in improvement

discussion Identify failures without pointing fingers Identify needs on how to improve

Take Action!

Taking Action…..

Process 1Share denial data, hold weekly meetings, remove the excuses,

identify key stakeholders and share accountability

Process 2Educate on payor guidelines,

understand how to use system, identify tools that work, develop tools

to meet needs

Process 3New reports, leadership involvement,

Access database

Process 4Confirm that efforts match results and

maintain accountability

October – December Denials

TOTAL NON-AUTH & ELIGIBILITY DENIALSADMIT DATE BEFORE/AFTER 10/1/11

NON-AUTH & ELIGIBILITY DENIALS RESULTING IN A YAA

ADMIT DATE BEFORE/AFTER 10/1/11

Denial Category Count Dollars Count Dollars Adj Amount

DOS After 10/01/11 1,287 $5,666,449 38 $517,384 ($36,915)

Eligibility 571 $1,929,850 21 $276,508 ($737)

Non-Auth/ MCD Non-Covered 34 $115,572 3 $12,031 ($49)

Non-Auth/ No PCP Referral 476 $440,086 3 $2,045 ($4,397)

Non-Auth/ Precert 206 $3,180,942 11 $226,800 ($31,732)

DOS Before 10/01/11 2,626 $10,654,903 252 $363,665 ($269,859)

Eligibility 1,197 $3,682,139 102 $105,675 ($14,859)

Non-Auth/ MCD Non-Covered 54 $423,483 4 $11,333 ($291)

Non-Auth/ No PCP Referral 976 $944,164 126 $91,916 ($220,807)

Non-Auth/ Precert 399 $5,605,116 20 $154,741 ($33,902)

Grand Total 3,913 $16,321,352 290 $881,049 ($306,774)

Gross denials and the resulting YAA posted for DOS after October 1, 2011

• Performance Measurement• Ins Ver Secure Rate (Scheduled)• Ins Ver Due Diligence Complete Rates (Non-Scheduled)• PreReg Completion Percentage• Ins Ver and PreReg Days Out

• Authorizations Obtained/Completed• Financial Counseling Sessions Completed

• 100% Inpatient• 90% Emergency Department• 80% Outpatients with Bad Debt and/or High Risk Score

• B/D and Charity Care Adjustments• Claim Edits, Rejections, and Denials• Yield Affecting Adjustments

Metrics to be monitored

•Loss of Revenue due to denials that result in Yield Affecting Adjustments

•Lack of automation to fully assist with cross-department work flow

•Poor communication between the various department

•Inefficiencies that result in rework across the revenue cycle

Lessons LearnedLeveraging technology is crucial to achieving high performancestandards in a volume-driven environment and the increase ofMedicaid patients will impact those who are not ready.

The lack of collaboration across service teams will negatively affectorganizations resulting in the following:

Questions?