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Navigating the Waters of Health Care Reform and Keeping your Health Care Plan Afloat

Navigating the Waters of Health Care Reform and Keeping your Health Care Plan Afloat

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Navigating the Waters of Health Care Reform and Keeping your Health Care Plan Afloat

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Presentation Transcript

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

  2. Health Plan Pressures Health Plan Provider Fraud & Abuse

  3. Fraud & Abuse 30% of all medical bills contain errors -Stephen Parente, professor of health finance at the University of Minnesota

  4. Fraud & Abuse

  5. Fraud & Abuse

  6. Fraud & Abuse

  7. Fraud & Abuse

  8. Fraud & Abuse

  9. Health Plan Pressures Health Plan Escalating Costs Provider Fraud & Abuse

  10. Escalating Costs

  11. Escalating Costs

  12. Escalating Costs

  13. TechnologicalAdvancements Health Plan Escalating Costs Provider Fraud & Abuse

  14. Technological Advancements • Specialized Radiology • Genetic Testing • Robotics

  15. Rx Costs & Advancements TechnologicalAdvancements Health Plan Escalating Costs Provider Fraud & Abuse

  16. 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%

  17. Rx Costs • Contributors to Rx Costs • Double Digit Inflation • Specialty Medications • Sole Source Brand Name Medications • Direct Patient Marketing • Consumer Choice = Less Cost Effective Choices • Physician Over Prescribing

  18. Rx Costs & Advancements Over Charging & Unbundling TechnologicalAdvancements Health Plan Escalating Costs Provider Fraud & Abuse

  19. Bundled vs. Unbundled Dialysis Claim Comparison Original Bundled Charges AWAC Savings

  20. Rx Costs & Advancements Over Charging & Unbundling TechnologicalAdvancements Treatment Protocol Changes Health Plan Escalating Costs Provider Fraud & Abuse

  21. Treatment Protocol Changes • Off-Label Use of Medication • Physician Dispensing

  22. Rx Costs & Advancements Over Charging & Unbundling TechnologicalAdvancements Treatment Protocol Changes Health Plan Escalating Costs Participant Expectations Provider Fraud & Abuse

  23. Participant Expectations 100% Coverage 100% Employer Paid No Out of Pocket Expenses Utilize any Physician, Hospital, or Clinic No Pre-Existing Condition Exclusions Enrollment Upon Demand

  24. Rx Costs & Advancements Over Charging & Unbundling TechnologicalAdvancements Treatment Protocol Changes Health Plan Escalating Costs Participant Expectations Provider Fraud & Abuse PPACA

  25. 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

  26. Wellness Communication Pre-Certification/Case Management data Reporting data Keeping Your Health Plan Afloat Rx Management Disease Management Claims Administration

  27. Wellness • Health Risk Assessment • Biometric Screening • Education-Goal Driven • Rewards • Results • Participation • ROI- $1 of Investment = $3 of Return Over 3 Years

  28. Pre-CertificationCase Management • 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

  29. Disease 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.

  30. Claims Administration • 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

  31. Rx Management • 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 Choices including Physician Communication • Data…Data…Data

  32. 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. ”

  33. Communication • “ 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

  34. 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.

  35. 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.

  36. Thank You P.O. Box 1688Pascagoula, MS 39568-1688(228) 762-2500 Phone(800) 530-7222 Toll Free(228) 769-0401 Fax