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Covered California

Covered California. Keep calm and keep asking questions. Covered California Health Plans. Metal Tier Benefit Levels. Bronze Silver Gold Platinum. HOSPITAL A - Plan ID’s #1 (1 hospital). Plan ID’s #2 & 3 (Bronze Level Plan ID’s). HOSPITAL B - Plan ID’s NO PENDING.

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Covered California

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  1. Covered California Keep calm and keep asking questions

  2. Covered California Health Plans CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  3. Metal Tier Benefit Levels • Bronze • Silver • Gold • Platinum CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  4. HOSPITAL A - Plan ID’s #1 (1 hospital) CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  5. Plan ID’s #2 & 3 (Bronze Level Plan ID’s) CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  6. HOSPITAL B - Plan ID’s NO PENDING CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  7. HOSPITAL C - Plan ID’s CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  8. Identification Easy ID? CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  9. 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

  10. Blue Shield Eligibility Enhanced PPO = Silver CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  11. Health Net – no level listed CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  12. 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

  13. 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

  14. 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

  15. Other Complications • Health plan receives matching federal funds • Patients do not have checking accounts –working on a cash payment process at stores CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  16. Eligibility Examples

  17. 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 readand not verified. CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  18. What Health Plan should we use? • Health Net Gold • Health Net Pending • Health Net bronze • Private Pay CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  19. What Health Plan should we use? - Answer • 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

  20. Changes Made • Reminder to Reverify benefits on month end • Reminder to verify demographics and unclear writing • Educate the clinical staff CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  21. 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

  22. 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

  23. Changes Made • Follow up with the patient prior to month end to pay the premium • Ask for proof of payment CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  24. 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

  25. What Health Plan(s) should we use? • Blue Shield • Blue Shield/Medi-Cal • Other Non-Contracted • Other Non-Contracted/Medi-Cal • Medi-Cal CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  26. 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

  27. Other Issues • Cancer patients are changed to HMO during treatment, treatment is stopped until the assigned HMO can see the patient • Non-Contracted Covered California is paying $500/day, excluding co-pay • What else? CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  28. Business Office Operations effects – So far….

  29. 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

  30. 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

  31. Actual Account Follow up #2 • 1/6/14 – Pt Admittedto 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

  32. Health Plan Weirdness • Medi-Cal AND Covered California Managed Care • LA Care Mismatched systems • ? • ? CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  33. 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

  34. 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

  35. 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

  36. 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

  37. Surprising Goal • Otani Consulting Group, Inc. • Lynn.Otani@otaniconsulting.com • (310) 346-1958 CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

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