Navigating the Waters of Health Care Reform and Keeping your Health Care Plan Afloat Jim Williams,...

Navigating the Waters of Health Care Reform and

Keeping your Health Care Plan Afloat

Jim Williams, Benefit Specialist

Health Plan

Provider Fraud & Abuse

Health Plan Pressures

30% of all medical bills contain errors-Stephen Parente, professor of health finance at the University of Minnesota

Fraud & Abuse

Fraud & Abuse

Health Plan


Escalating Costs

Health Plan Pressures

Escalating Costs

Health Plan


Escalating Costs

Technological

Advancements

Technological Advancements

Specialized Radiology

Genetic Testing

Robotics

Health Plan


Escalating Costs

Technological

Advancements

Rx Costs & Advancemen

ts

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 InflationSpecialty MedicationsSole Source Brand Name MedicationsDirect Patient Marketing

• Consumer Choice = Less Cost Effective Choices

• Physician Over Prescribing

Health Plan


Escalating Costs

Technological

Advancements


ts

Over Charging & Unbundling

Bundled vs. Unbundled Dialysis Claim Comparison

Account # Patient Name AWACDialysis Facility Client ARP11/16/10-11/20/10 Item Charge Units Rate Rate Variance

90999 Hemodialysis treatment$5,820.00 3 $5,820.00 $1,001.17 $4,818.83 H6J 1270 Hectorol $1,168.00 12 $1,168.00 $51.69 $1,116.31 1J 1644 Heparin $0.00 24 $0.00 $0.00 $0.00 H6J 1756 Venofer $785.00 100 $785.00 $237.36 $547.64 H6Q4081 Epogen $2,804.25 319 $2,804.25 $436.00 $2,368.25 2A4657 Administration of drug$1,023.75 19 $1,023.75 $0.00 $1,023.75 H6

Total $11,601.00 $11,601.00 $1,726.22 ($9,874.78)

(1) Medical documentaion does not support 6 mcgs of Hectorol.

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 asmedications that did not meet medical appropriateness.

(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.

Original Bundled Charges

AWAC Savings

Health Plan


Escalating Costs

Technological

Advancements


ts


Treatment Protocol Changes


Off-Label Use of Medication

Physician Dispensing

Health Plan


Escalating Costs

Technological

Advancements


ts



Participant Expectations

100% Coverage 100% Employer

PaidNo Out of Pocket

ExpensesUtilize any

Physician, Hospital, or Clinic

No Pre-Existing Condition Exclusions

Enrollment Upon Demand


Health Plan


Escalating Costs

Technological

Advancements


ts




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

PPACA

Keeping Your Health Plan Afloat

Wellness Pre-

Certification/Case Management

Disease Management

Claims Administration

Rx Management

Reporting

Communication

data

data

Health Risk AssessmentBiometric ScreeningEducation-Goal DrivenRewards• Results• Participation ROI- $1 of Investment = $3 of Return Over 3

Years

Wellness

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

Pre-CertificationCase 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.

Disease Management

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

Claims Administration

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

Choicesincluding Physician Communication

Data…Data…Data

Rx Management

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. ”

“ 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

Communication

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 1688Pascagoula, MS 39568-1688

(228) 762-2500 Phone(800) 530-7222 Toll Free

(228) 769-0401 Fax

Navigating the Waters of Health Care Reform and Keeping your Health Care Plan Afloat Jim Williams,...

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