TIPS ON HOW TO SURVIVE TIPS ON HOW TO SURVIVE WITH SHRINKING WITH SHRINKING

PAYMENTS & GROWING PAYMENTS & GROWING HIGH-DEDUCTABLE HIGH-DEDUCTABLE

HEALTH PLANSHEALTH PLANS

Kathy Whitmire

www.OPATH.net

March 24, 2009

Why are Payments Why are Payments Shrinking?Shrinking?

Changes to Payment Changes to Payment Requirements without proper Requirements without proper educationeducation

Medicare Budget & Contract Medicare Budget & Contract ReformReform MIPAA, MAC, RACMIPAA, MAC, RAC

Large Commercial Payers Large Commercial Payers following suit with Medicarefollowing suit with Medicare Promotion of New HDHP’s & HRA’sPromotion of New HDHP’s & HRA’s

What can you do about What can you do about it?it?

Stay InformedStay InformedCMS – MedicareCMS – Medicare http://www.cms.hhs.gov/center/physician.asphttp://www.cms.hhs.gov/center/physician.asp

E-Prescribing Measure SpecificationsE-Prescribing Measure Specifications qualify for a 2% incentive payment for 2009qualify for a 2% incentive payment for 2009

2009 PQRI2009 PQRI earn an incentive payment of 2.0 percent of their total earn an incentive payment of 2.0 percent of their total

allowed charges for Physician Fee Schedule (PFS) allowed charges for Physician Fee Schedule (PFS) Value-Based Purchasing Program Value-Based Purchasing Program

Plan To Transition to a Medicare VBP for Physician and Plan To Transition to a Medicare VBP for Physician and Other Professional Services Other Professional Services

Stay InformedStay Informed

Cahaba GBA Georgia Part B http://www.cahabagba.com/j10/index.

htm

Cutover Date - 08/03/2009

State Health Benefit PlanState Health Benefit Plan http://dch.georgia.gov/00/channel_titlehttp://dch.georgia.gov/00/channel_title

/0,2094,31446711_32021041,00.html/0,2094,31446711_32021041,00.html

MEDICARE Payment MEDICARE Payment ShrinkageShrinkage

E-Prescribing Measure SpecificationsE-Prescribing Measure Specifications Beginning January 1, 2009, eligible professionals (EP) Beginning January 1, 2009, eligible professionals (EP)

can participate by reporting on their adoption and can participate by reporting on their adoption and use of an e-prescribing system by submitting claims use of an e-prescribing system by submitting claims information on one e-prescribing measure on their information on one e-prescribing measure on their Medicare Part B claims.Medicare Part B claims.

The specifications for reporting the measure that will The specifications for reporting the measure that will

be used to determine if an (EP) eligible professional be used to determine if an (EP) eligible professional is a successful e-prescriber and qualify for a is a successful e-prescriber and qualify for a 2% 2% incentive payment for 2009incentive payment for 2009 can be found in the can be found in the "Downloads""Downloads" section. This document also provides section. This document also provides the definition of a "qualified e-prescribing system." the definition of a "qualified e-prescribing system." 

MEDICARE Payment MEDICARE Payment ShrinkageShrinkage

2009 PQRI.2009 PQRI. Physician Quality Reporting InitiativePhysician Quality Reporting Initiative The Medicare Improvements for Patients and Providers The Medicare Improvements for Patients and Providers

Act of 2008 (MIPPA) (Pub. L. 110-275) made the PQRI Act of 2008 (MIPPA) (Pub. L. 110-275) made the PQRI program permanent, but only authorized incentive program permanent, but only authorized incentive payments through 2010. payments through 2010.

EPs who meet the criteria for satisfactory submission of EPs who meet the criteria for satisfactory submission of quality measures data for services furnished during quality measures data for services furnished during the reporting period, January 1, 2009 - December 31, the reporting period, January 1, 2009 - December 31, 2009, will earn an 2009, will earn an incentive payment of 2.0 percent incentive payment of 2.0 percent of their total allowed charges for Physician Fee of their total allowed charges for Physician Fee Schedule (PFS)Schedule (PFS) covered professional services covered professional services furnished during that same period (the 2009 furnished during that same period (the 2009 calendar year).  calendar year).  

MEDICARE Payment MEDICARE Payment ShrinkageShrinkage

2009 VBP.2009 VBP. Value Based PurchasingValue Based Purchasing Program Objectives 1. Promote the practice of evidence-based

medicine through 2. Reduce fragmentation and duplication 3. Encourage effective management of chronic

disease 4. Accelerate the adoption of effective,

interoperable health information technology (HIT),

5. Empower consumers to make value-based health care choices and encourage health professionals to improve the value of care by disseminating transparent and useful information

  

MEDICARE UPDATEMEDICARE UPDATE

January 26, 2009:January 26, 2009: The new policy allows The new policy allows providers to be paid by the Medicare providers to be paid by the Medicare program for services delivered up to 30 program for services delivered up to 30 days before the date of submission of a days before the date of submission of a successful Medicare enrollment application.successful Medicare enrollment application.

CY 2009 Medicare Physician Fee Schedule.CY 2009 Medicare Physician Fee Schedule.Section 42 CFR 424.521(a). This provision allows a Section 42 CFR 424.521(a). This provision allows a Medicare contractor to establish an effective date of Medicare contractor to establish an effective date of billing 30 days prior to the date of filing if the billing 30 days prior to the date of filing if the practitioner meets all other program requirements practitioner meets all other program requirements (e.g., licensing).(e.g., licensing).

No more retro billing further than 30 daysNo more retro billing further than 30 days This policy is effective as of January 1, 2009, This policy is effective as of January 1, 2009,

Enforcement of this provision and will begin actively Enforcement of this provision and will begin actively monitoring provider compliance with this provision monitoring provider compliance with this provision beginning on April 1, 2009. beginning on April 1, 2009. 

CAHABA UPDATECAHABA UPDATE

MAC Part B Cutover Date - 08/03/2009

The award of the J10 Part A/Part B Medicare Administrative Contractor (A/B MAC) contract is another step toward improved service to providers, physicians and practitioners as well as greater administrative efficiency and effectiveness for fee-for-service Medicare.

This award is indicative of the efforts underway to significantly reengineer the Medicare claims administration process and change from the “business as usual” of the past 40 years.

SHBP UPDATESHBP UPDATE

NEW ADDRESS FOR SHBP:NEW ADDRESS FOR SHBP:

State Health Benefit PlanState Health Benefit PlanP.O. Box 1990P.O. Box 1990Atlanta, Georgia 30301 Atlanta, Georgia 30301

SHBP UPDATESHBP UPDATE

BIG CHANGES:BIG CHANGES:

ONLY 2 OPIONS FOR NEW SHBP ONLY 2 OPIONS FOR NEW SHBP MEMBERS:MEMBERS:1) HDHP1) HDHP2) HRA 2) HRA

We must know and understand We must know and understand these new plans!!!!these new plans!!!!

SHBP UPDATESHBP UPDATE

Consumer Driven Health Plan Options

The Health Reimbursement Arrangement (HRA) and the High Deductible Health Plan (HDHP) are consumer driven health plan options. These options are structured to provide lower out-of-pocket expenses for many participants and are explained below.

HRAHRA

Health Reimbursement Arrangement (HRA) It is similar to that of a PPO with an in-network and out-of-

network benefit, except SHBP funds dollar credits to your HRA each year to provide first dollar coverage for eligible health care and pharmacy expenses. The amount in your HRA is used to reduce the deductible and maximum out-of-pocket.

After satisfying your deductible, you will pay your coinsurance amount until you reach your out-of-pocket maximum, at which time SHBP will pay 100 percent of eligible expenses for the remainder of the Plan Year.

EXAMPLE: An HRA member with itchy eyes received a doctor’s

prescription for drops that cost $82. Her pharmacist helped find $12 over-the-counter drops that did the same thing.

Savings to her HRA – $70.

HDHPHDHP

High Deductible Health Plan with a Health Savings Account (HSA) In return for a low monthly premium, you must satisfy a

high deductible that applies to all health care expenses except preventive care.

If you have family coverage, you must meet the ENTIRE family deductible before benefits are payable for any family member.

You pay co-insurance after you have satisfied the deductible rather than set dollar co-payments for medical expenses and prescription drugs.

Also, you may qualify to start a Health Savings Account (HSA) to set aside tax-free dollars to pay for eligible health care expenses now or in the future. HSAs typically earn interest and may even offer investment options.

HDHPHDHP

High Deductible Health Plan • This option offers 100 percent

unlimited wellness benefits based on national age and gender guidelines

• You must satisfy a separate in-network and out-of-network deductible and out-of-pocket maximum

• You pay co-insurance after meeting the entire family deductible for all medical expenses and prescriptions

HSAHSA

Health Savings AccountAn HSA is like a personal savings account

with investment options for health care, except it’s all tax-free. You may be eligible to participate in an HSA that is offered through the State of Georgia Flexible Benefits Program or by your employer. Participation through payroll deductions allows your contributions to be pre-tax.

COBRA UPDATECOBRA UPDATE

   COBRA subsidy/premium assistanceIf you have involuntarily lost your job with a state agency, school system, or other SHBP-covered group from September 1, 2008 to present, and were covered under SHBP at the time of the job loss, you may be entitled to elect COBRA with a 65% COBRA premium reduction (or, if already under COBRA, receive a premium reduction) effective March 1, 2009. 

COBRA Premium Assistance FAQsNew Wallet Card for CIGNA HRA MembersLoss of Coverage information

MAKE CHANGESMAKE CHANGES

Write New Policy to comply with Write New Policy to comply with changeschanges

Set up New Processes in your Set up New Processes in your practicepractice

Educate your staff and have Educate your staff and have them read & sign new policythem read & sign new policy

Audit Results – A/R AgingAudit Results – A/R Aging Remittance AdvicesRemittance Advices Denials Denials

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Hepatitis CHepatitis CInformed Consent: A Communication ProcessInformed Consent: A Communication Process

Risk Management: Protecting Patients, Protecting Your Practice Risk Management: Protecting Patients, Protecting Your Practice

ABN - Advanced Beneficiary NoticeABN - Advanced Beneficiary NoticeCMS 1500 Version 08/05CMS 1500 Version 08/05Health Insurance BasicsHealth Insurance Basics

Healthcare Compliance OverviewHealthcare Compliance OverviewHIPAA Basic TrainingHIPAA Basic Training

How to Be A Customer Service SuperstarHow to Be A Customer Service SuperstarManaged Care BasicsManaged Care BasicsMedical TerminologyMedical Terminology

Medical Terminology IIMedical Terminology IIAdvanced Customer Service Advanced Customer Service

Telephone EtiquetteTelephone EtiquetteYour Role in the Revenue CycleYour Role in the Revenue Cycle