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ADAP in Crisis: Cost Recovery Strategies

ADAP in Crisis: Cost Recovery Strategies. Presented to the ADAP Advocacy Association December 5, 2008. About HMS. Every year, HMS recovers $1 billion for our clients, and helps them avoid billions more in erroneous payments.

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ADAP in Crisis: Cost Recovery Strategies

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  1. ADAP in Crisis: Cost Recovery Strategies Presented to the ADAP Advocacy Association December 5, 2008

  2. About HMS Every year, HMS recovers $1 billion for our clients, and helps them avoid billions more in erroneous payments. HMS helps protect the integrity of government-sponsored health and human service programs.

  3. Who We Serve • 43 State clients • Medicaid • 36 Medicaid agencies • 88% of fee-for-service Medicaid population • Managed Care • 85 Medicaid managed care plans • Over 12 million Medicaid lives • CMS Audit Medicaid Integrity Contractor • Other Markets • Child Support agencies • Veterans Health Administration • Department of Defense

  4. More enrollees = more budgetary pressure 4

  5. The Opportunity for ADAP By identifying enrollees with private insurance, and recovering the cost of medications, ADAP programs can make the most of their existing resources and serve more people in need.

  6. Coordination of Benefits Data from 1000 Insurance Plans Claim Payment Claim & Beneficiary Data HMS PROCESS Patient Provider Pharmacy State Payor Medicaid ADAP Claim billed to Correct party $ Carrier 6

  7. HMS’s Third Party Identification and Recovery Capabilities • Nation’s largest eligibility database • Over 1,000 insurance plans in data match network • Continually updated with refreshed data • Sophisticated data match processes • Proven recovery processes • 88% of claims submitted electronically • Dedicated yield management function

  8. Case Study: New Jersey • HMS client since 1985 • More than $1 billion recovered • Comprehensive service portfolio • Insurance identification • Coordination of benefits (COB) • Near-real time Rx COB • Financial credit balance reviews • Clinical reviews

  9. Case Study: NJ ADDP Program • Covers about 6,000 individuals • Pays 290,000 claims annually • Maintains relatively open formulary • Expends $74 million in Rx claims (2007)

  10. Services for NJ ADDP • Identification of liable third parties • Verification of coverage • Accretion of coverage to State MMIS • Pharmacy coordination of benefits • Lockbox services • Management reporting

  11. Results for NJ ADDP • $47.5 million in recoveries since 1995 • $5.8 million in recoveries in 2007 • Where private coverage is identified, all future claims immediately routed to liable carrier • Progressive reduction in payment error rate

  12. Opportunities for ADAPs • Third party identification and recovery 2. Real-time coordination of benefits 3. Payment accuracy through clinical and pharmacy audits

  13. Questions?

  14. HMS Contacts Kevin Lee, Regional Vice President 609.588.0471 klee@hms.com Lori Karaian, Director of Govt. Relations 704.927.8310 ext. 8225 lkaraian@hms.com

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