Covered CaliforniaKeep calm and keep asking questions
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
Covered California Health Plans
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
Metal Tier Benefit Levels
• Bronze
• Silver
• Gold
• Platinum
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
HOSPITAL A - Plan ID’s #1 (1 hospital)
Plan Name/INSURANCE NAME ELIG PYR
Blue Shield PPO DMD05664
Health Net PPO DMD12345
Health Net Community Care HMO DMD23456
Anthem BX EPO DMD34567
Anthem BX HMO DMD45678
KAISER HMO DMD56789
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
Plan ID’s #2 & 3 (Bronze Level Plan ID’s)
PEND PYRPlan Name/INSURANCE NAME (Pending elig/premium) ELIG PYR Plan Name/INSURANCE NAME (eligible )
IHI070BA BLUE CROSS EPO-PEND CVD CA IHI070B1 BLUE CROSS EPO BRZ-CVD CA
IHI070BB BLUE CROSS HSA -PEND CVD CA IHI070B2 BLUE CROSS HSA BRZ-CVD CA
IHI186BA HEALTH NET PPO -PEND CVD CA IHI186BB HEALTH NET PPO BRZ-CVD CA
IHI056BA BLUE SHIELD EPO HSA-PEND CVD CA IHI056B1 BLUE SHIELD HSA BRZ-CVD CA INDEM
IHI056BB BLUE SHIELD PPO-PEND CVD CA IHI056B2 BLUE SHIELD PPO BRZ-CVD CA INDEM
IHI217BA KAISER HMO HSA-PEND CVD CA IHI217B1 KAISER HMO HSA BRZ-CVD CA INDEM
IHI217BB KAISER HMO-PEND CVD CA IHI217B2 KAISER HMO BRZ-CVD CA INDEM
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
HOSPITAL B - Plan ID’s NO PENDING
COVERED CALIFORNIA ELIG PYR Plan Name
12345 BLUE CROSS CVD CA 45678 BLUE CROSS ANTHEM
74184 HEALTH NET CVD CA 74185 HEALTH NET PPO
60331 BLUE SHIELD HSA INDEM
60332 BLUE SHIELD PPO
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
HOSPITAL C - Plan ID’s
COVERED CALIFORNIA ELIG PYR Plan Name
Trying to add BLUE CROSS CVD CA 45678 BLUE CROSS ANTHEM
74185 HEALTH NET PPO
60331 BLUE SHIELD HSA INDEM
Trying to add Blue shield PPO 60332 BLUE SHIELD PPO
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
Identification
Easy ID?
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
EASY –
Anthem BRONZE Card
CHANGED STANDARD DEFINITIONS!
Basic PPO = Bronze; Enhanced PPO = Silver
Preferred PPO = Gold; Ultimate PPO = Platinum
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
Blue Shield Eligibility
Enhanced PPO = Silver
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
Health Net – no level listed
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
Covered CA Identification
• Eligibility – IFP does not show icon
• Eligibility systems do not always show Covered CA benefits
• Health Plan employees do not always know
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
Premium Payments
• Old Methodology – Employer Pays premiums and deducts employee amount from pay check
• Covered California Methodology – Patient pays premiums, has 90 days to pay
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
Premium payment methods
• Health Plan – best
• Broker – can cause delay in eligibility
• Covered CA – delay in eligibility
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
Other Complications
• Health plan receives matching federal funds
• Patients do not have checking accounts –working on a cash payment process at stores
Eligibility Examples
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
COVERAGE ELIGIBILITY– month to month Pt. Discharged – what health plan?
• Jane Kawabunga is admitted on March 31st as Health Net gold and is verified as covered.
• Jane is discharged on April 2nd and leaves the hospital before Patient Access can speak to her because the nurses did not call to say that she was leaving.
• Patient Access checks the eligibility vendor and calls Health Net but cannot validate April coverage.
• PA cannot talk to Jane because she is staying at her boyfriend’s and the wrong phone # was entered from the demog sheet which was difficult to read and not verified.
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
What Health Plan should we use?
1. Health Net Gold
2. Health Net Pending
3. Health Net bronze
4. Private Pay
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
What Health Plan should we use? - Answer
1. Health Net Gold
Leave the original plan ID because the patient was verified as covered at time of admission.
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
Changes Made
1. Reminder to Reverify benefits on month end
2. Reminder to verify demographics and unclear writing
3. Educate the clinical staff
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
COVERAGE ELIGIBILITY– month to month – Pt. In-house
• John Kawabunga is admitted on April 30th as Health Net gold and is verified as covered.
• On May 1st Patient Access checks eligibility vendor and calls Health Net but cannot validate May coverage.
What do we do?
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
COVERAGE ELIGIBILITY– month to month – Pt. In-house
• Follow hospital procedure and talk to the patient/family – avoid letters at bedside
• Verify premium payment or expected payment date
• DOCUMENT discussion with patient/family (name, relationship, request, outcome)
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
Changes Made
1. Follow up with the patient prior to month end to pay the premium
2. Ask for proof of payment
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
What Health Plan(s) should we use?
• Mortimer Applebush is admitted to Behavioral Health
• Morty (his aka) has Blue Shield/Arta
• We are contracted with Blue Shield/Arta, however, upon calling to verify coverage, it is found that Behavioral Health is carved out to MHSA and not contracted at this facility after providing the facility tax ID.
• Morty has Medi-Cal secondary.
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
What Health Plan(s) should we use?
1. Blue Shield
2. Blue Shield/Medi-Cal
3. Other Non-Contracted
4. Other Non-Contracted/Medi-Cal
5. Medi-Cal
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
What Health Plan(s) should we use?
4. Other Non-Contracted/Medi-Cal
We will bill Blue Shield because Medi-Cal will deny if there is other coverage.
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
Other Issues
1. Cancer patients are changed to HMO during treatment, treatment is stopped until the assigned HMO can see the patient
2. Non-Contracted Covered California is paying $500/day, excluding co-pay
3. What else?
Business Office Operations effects – So far….
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
Eligibility
• No change seen yet in the eligibility process
• Increased expanded Medi-Cal
• Increased Presumptive Eligibility = increased follow up to ensure Medi-Cal application completion
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
Actual Account Follow up #1• 1/1/14 – Pt Admitted, Pt had not received insurance card
• 1/2/14 – Received Ins Info from the patient, called Blue Shield, no record of pt
Pt states premium was paid
• 1/7/14 – Called Blue Shield, obtained benefits:
PPO, no ded; 80%; no mention of Covered CA
• 1/17/14- Received Insurance Card with Covered CA icon
• Jan/Feb – Follow up calls
• 3/3/14 – Cld Ins: Total charges, $39,000, Pmt $2,000;
Pt Liability $15,000
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
Actual Account Follow up #2• 1/6/14 – Pt Admitted to ED Trauma, pt intubated, rec’d demog info from sister, no ins
info
• 1/8/14 – Spouse states Blue Shield Silver, premium paid 1/6, presented BS invoice
• 1/8/14 – Called Blue Shield, no record of patient (daily calls to Blue Shield)
• 1/11/14- Patient expired
• 1/13/14 – Blue Shield gave benefits, cannot pre-cert due to expiration, bill with med rec
• 1/22/14 – billed with med recs and trauma info
• Feb 2014 – called for status and potential missing information and checked website for follow up
• 3/5/14 – Blue Shield denied for documentation
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
Health Plan Weirdness• Medi-Cal AND Covered California Managed Care
• LA Care Mismatched systems
• ?
• ?
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
Low benefits/No explanation
• Patient Admitted with bronze plan in March:
$5,000 deductible, then $500 per day
- Patients AND some counselors do not understand coverage
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
Other Issues
• Increased Patient Anger
• Health Plan confusion as to what is covered
• Incorrect website information regarding contracted hospitals
• Covered California impacts non-Covered California plans
• Plans won't deny policy based on pre-existing but won’t pay
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
Surprising Goal
• Increased patient education
• Assist with plan level selection PRIOR to open enrollment
• Education on benefits
• Increased dialog while in house
• Increased physician education
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
Solution
• On-site Financial Patient Advocate
• Helps patients navigate through the proces• Insurance eligibilty
• Sponsored Care
• Sort through bills
• Redetermination for Medi-Cal
• Workers Comp
CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014
Surprising Goal
• Otani Consulting Group, Inc.• [email protected]
• (310) 346-1958