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Managed Care 101

Managed Care 101. Kelly Partin. Agenda. Key Terms Types of Insurance Inside an Insurance Company Carve Outs (Pharmacy, Mental Health, Vision). Key Terms - Network.

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Managed Care 101

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    1. MAHAP General Session February 19, 2010 1 Managed Care 101 Kelly Partin

    2. MAHAP General Session February 19, 2010 2 Agenda Key Terms Types of Insurance Inside an Insurance Company Carve Outs (Pharmacy, Mental Health, Vision)

    3. MAHAP General Session February 19, 2010 3 Key Terms - Network Provider Network The list of providers who are contracted or enrolled with a Health Insurance Company or Government Agency to provide care for a given set of people. Participating (Par Provider / Contracted Provider) The term used to describe providers that are part of a Provider Network.

    4. MAHAP General Session February 19, 2010 4 Key Terms Insurance Types Risk Who ultimately has to pay for the claim. The group who pays the provider is frequently not the one who has to budget for the cost of medical care! Upside Risk A method used in contracting to provide incentives the providers to keep health care costs low. Risk Pool An account of funds set aside that are designated for one or multiple purposes

    5. MAHAP General Session February 19, 2010 5 Key Terms - Claims HCFA 1500 The Standard Claim form for a Professional Claim UB 04 the Standard Claim Form for a Facility Adjudication The process of entering the claim information into a claims processing software program, reviewing the claim, and paying or denying a claim Auto Adjudicate Adjudicating a claim without a person looking at the individual claim using a rules based software system

    6. MAHAP General Session February 19, 2010 6 Types of Health Insurances (Product Lines)

    7. MAHAP General Session February 19, 2010 7 Traditional Insurance (Blue Cross Blue Shield) Health Maintenance Organizations (HMO) Preferred Provider Organizations (PPO) Government Programs (traditional Medicare, Medicaid, Tri-Care) Odds and Ends: Workers Compensation, Motor Vehicle, Gap Plans for Medicare Types of Insurances Overview

    8. MAHAP General Session February 19, 2010 8 Types of Insurances Traditional Insurance Origin: 1929, Physician groups began offering medical care to groups of people at a flat rate (per member per month) Example: Blue Cross Blue Shield Insurance Company is at Risk

    9. MAHAP General Session February 19, 2010 9 Types of Insurances Traditional Insurance, cont Mostly Group Coverage Deductibles and % co-pays Very little if any medical management Large Enrolled Network

    10. MAHAP General Session February 19, 2010 10 Key Terms PPO Preferred Provider Organization A company that contracts with health care providers to create a network. They then lease the network to employer groups (via TPAs) health plans. Sometimes they can be owned / operated by a TPA (Aetna, Cigna) or operate independently (Great West Life, Multiplan) Third Party Administrator An entity that provides Member Services & Claims Processing (examples Meritain Health, CAM Administrators, Pharmacare)

    11. MAHAP General Session February 19, 2010 11 Types of Insurances PPO Employer / Group based insurance Employer is generally at risk Benefits are dependent upon individual group Vary GREATLY Look to a Plan Document for benefit coverage Governed by ERISA - Federal

    12. MAHAP General Session February 19, 2010 12 Employer group contracts for a network ( PPO) and a TPA to manage the benefit PPO prices the claim and forwards onto the TPA (from time to time the TPA will receive the claim and forward to multiple PPOs to price and pick which is best) TPA pays the claim and bills the employer for the cost of the claim + a fee TPA prints the ID Card Process PPOs

    13. MAHAP General Session February 19, 2010 13 Types of Insurances PPO cont. Some to no Medical Management Network larger than HMO and smaller than Indemnity Some provider credentialing

    14. MAHAP General Session February 19, 2010 14 Silent PPOs Silent PPO does not have the logo on the card. Rarely drives business to the provider, just allows the payer to take a discount after the fact Modify Contract language to require logo on card Example: Beech Street

    15. MAHAP General Session February 19, 2010 15 Wrap Around Networks Wrap Around Network A health care provider Network used as a second option to a primary, more preferred health care provider. Used for many reasons, which can include: Filling in holes, such as creating a National Network for traveling members Provide a more comprehensive network while directing patients to a more cost effective network.

    16. MAHAP General Session February 19, 2010 16 Wrap Around Networks Examples: Botsfords PPO network Botsford is the preferred provider with Blue Cross as a wrap Health Plus uses a large PPO for out of state coverage Humanas Commercial Product Line uses Cofinity as a wrap

    17. MAHAP General Session February 19, 2010 17 High Deductible Health Plan a.k.a. Consumer Driven Health Plan (CDHP) is a benefit design that allows for high deductibles that encourages ownership of medical care Idea: Consumers will shop around to get the least expensive and medically necessary medical care

    18. MAHAP General Session February 19, 2010 18 High Deductible Health Plan cont Employers or employees can put money in a Health Savings Account (not MSA) that rolls over year to year to be used toward medical expenses

    19. MAHAP General Session February 19, 2010 19 Key Terms Medical Management Referral A written document from one provider to another (Family Physician refers a patient to an ENT) Authorization An approval from a Insurance Company that the services are considered medically necessary and therefore a covered benefit HEDIS Health Employer Data Information Set Established by NCQA, a set of data elements to score a Health Plan on the quality of care members receive

    20. MAHAP General Session February 19, 2010 20 Types of Insurances HMO Insurance Company is at Risk May share risk with providers, but generally limited to upside risk May share risk with Employer Group Licensed by Office of Financial and Insurance Regulation offers the HMO consumer guide (http://www.michigan.gov/dleg/0,1607,7-154-10555_13222_13224-34152--,00.html)

    21. MAHAP General Session February 19, 2010 21 Types of Insurances HMO, Cont. Benefits are generally more comprehensive with flat co-pays and low deductibles (regulated) May now offer CDHPs not as common Heavy Medical Management including PCPs Smaller networks Provider credentialing (requirement of NCQA)

    22. MAHAP General Session February 19, 2010 22 Staff Model HMO Was the original design of an HMO The physician group is at risk One stop shop for comprehensive care Sometimes called Clinic System Difficult to sustain because of low numbers of membership

    23. MAHAP General Session February 19, 2010 23 PACE Program Members / Patients go to a center for medical care, coordinated by an employed physician (PCP) and receive coordinated comprehensive medical care Covered services include: all medical care (including hospital, home health, specialty), DME, home modifications, many meals, social services, medical transportation, therapy, personal care attendants, hospice care, prescriptions, adult day care, & nursing home care (if needed).

    24. MAHAP General Session February 19, 2010 24 Qualify for PACE Program Live in the service area Be 55 years or older Medically qualify for skilled nursing care Qualify for Medicare Capitated benefit funded by Medicare and Medicaid

    25. MAHAP General Session February 19, 2010 25 PACE Programs in Michigan 2 Programs in Michigan Henry Ford Health System-Center for Senior Independence 313-653-2020 Care Resources (Grand Rapids) 800-610-6299 If we have a PACE patient at Botsford Call the appropriate PACE program for approval they will be the one paying the bill!

    26. MAHAP General Session February 19, 2010 26

    27. MAHAP General Session February 19, 2010 27 Medicare

    28. MAHAP General Session February 19, 2010 28 Types of Government Coverage Medicare To qualify you must Be 65 years or older OR disabled for 24 months OR have end stage renal failure AND have worked and paid FICA taxes for 40 quarters (prorated for disabled) or have a spouse who has worked and paid FICA taxes No Financial requirements No requirement to reside in the U.S.

    29. MAHAP General Session February 19, 2010 29 Types of Government Coverage Medicare, cont. Funded by the Federal Government Coverage is not medically managed Providers simply enroll (no credentialing) No Accreditation Large Deductibles and co-insurance Entitlement Program

    30. MAHAP General Session February 19, 2010 30 Types of Government Coverage Medicare Parts Part A Hospital and Facility Coverage Usually free (UB claims) Part B - Physician Services and other professional (ambulance, physician, HCFA claims) Part C Simply funds the Medicare Advantage Plan Part D Prescription Plans All coordinated through a Carve Out Pharmacy Benefit Manager (PBM)

    31. MAHAP General Session February 19, 2010 31 Types of Government Coverage Medicare Gap Plans - Medigap Because Medicare covers very little Medigap is born Follows Medicare Primary Payor Rules (if Medicare says Ok, Ill pay..) Plans are required to follow a certain benefit design determined by OFIS Plans A through J

    32. MAHAP General Session February 19, 2010 32 Medicare Advantage Plans Pays like Medicare (except bad debt) About 20% of Medicare enrollees are in a Medicare Advantage Plan Many times offer richer benefits (lower co-pays, deductibles) and additional coverage such payment for gyms

    33. MAHAP General Session February 19, 2010 33

    34. MAHAP General Session February 19, 2010 34 Types of Government Coverage Medicaid Multiple Programs Some for Disabled or elderly Others for low income dependents with children Must have financial need (MedicAID) Requirements for residency, citizenship, etc. Mostly administered by State (SSI administered by Social Security Admin.)

    35. MAHAP General Session February 19, 2010 35 Types of Government Coverage Medicaid cont. Funded by the Federal Government and State Government Coverage is not medically managed Providers simply enroll (no credentialing) No Accreditation Low co-pays if any Payor of Last Resort

    36. MAHAP General Session February 19, 2010 36

    37. MAHAP General Session February 19, 2010 37 Childrens Special Health Care Services (CSHCS) A program through the State of Michigan (available in all states) that offers Case Management services to children who are disabled. May also offer additional coverage based upon financial need. (camps, ramps, medical care, etc.) Does not need to qualify financially, however, may cost a nominal fee if not on Medicaid.

    38. MAHAP General Session February 19, 2010 38 Childrens Special Health Care Services (CSHCS), cont. To qualify Michigan Resident UScitizen or documented non-citizen admitted for permanent residence or a non-citizen legally admitted migrant farm worker (i.e. seasonal agricultural worker). Age: Children must have a qualifying medical condition and be 20 years old or under. Person 21 and older with cystic fibrosis or certain hereditary blood coagulation disorders commonly known as hemophilia may also qualify. Qualifying Medical condition: A MDCH medical consultant reviews each case to determine eligibility. Severity and chronicity of the person's condition as well as the need for treatment by a specialist are factors considered. More than 2,500 diagnoses are potentially eligible. Click here for a list of these diagnoses CSHCS Family Phone Line at 1-800-359-3722

    39. MAHAP General Session February 19, 2010 39 Other Government Programs Tri-Care Government program for Military Offers a PPO network and a smaller HMO network (based upon Need) Enrollment based only

    40. MAHAP General Session February 19, 2010 40 Odds and Ends Workers Compensation A requirement for most businesses Some companies use a PPO network (First Health) State Fee Schedule

    41. MAHAP General Session February 19, 2010 41 Odds and Ends Motor Vehicle Coverage Most policies in Michigan have a caveat that the other Health Insurance Coverage is PRIMARY (keeps cost of auto insurance lower) Many use Cofinity (a.k.a. PPOM) as a network when necessary

    42. MAHAP General Session February 19, 2010 42 Internal Structures

    43. MAHAP General Session February 19, 2010 43 Provider Contracting & Provider Relations Claims Department Member Services Medical Management Information Technology (no slide) Underwriting (in Commercial) (no slide) Internal Structures for Traditional Insurances and HMOs

    44. MAHAP General Session February 19, 2010 44 Provider Contracting & Provider Relations HMOs and PPOs contract with Providers to create a network. Provider Relations create a Provider Manual that explains policies and procedures Responsible for provider communications, often a requirement of Accreditation

    45. MAHAP General Session February 19, 2010 45 Claims Department Enters a claim (electronically, OCR, data entry) into a software program Requests additional information from Provider, denies, or pays the claim In many organization, large number of claims (80% and more) are auto adjudicated Never to be seen by a human.

    46. MAHAP General Session February 19, 2010 46 Member Services Member is anyone covered under the insurance Many times resolves complaints and grievances Member Services is responsible for all member communications Newsletters (requirement for Accreditation) Member Handbook Call Center outgoing

    47. MAHAP General Session February 19, 2010 47 Medical Management GOAL: Improve member health thus reducing medical care Will track HEDIS Measures and Bed Days / # of admissions Medical Director (MD / DO) Nurses will review high dollar services (inpatient admissions, some surgeries, etc.) and provide a prior authorization for care Develop policies regarding what is considered medically necessary May use an Imaging Service (AIM) to review radiology services for prior authorizations

    48. MAHAP General Session February 19, 2010 48 Medical Management Quality Improve the care members receive by reducing barriers Increase the number of members who receive HEDIS measures tracked Patients may be eligible for added benefit

    49. MAHAP General Session February 19, 2010 49 Medical Management Case Management Telephonic Case Management Typically manage Cardiac, some Asthma, Cancer, Transplant, and other chronic patients Patients may be eligible for added benefit

    50. MAHAP General Session February 19, 2010 50 WHY ? Reduce costs! Improve Medical Care US News Top 10 Commercial in MI 09-10 Grand Valley Health Plan 89.4 Priority Health 86.9 HealthPlus of MI 86.1 Physicians Health Plan of Mid Michigan 85.7 HAP 85.4 BCN 84.5

    51. MAHAP General Session February 19, 2010 51 Carve Outs Mental Health (Value Options) Pharmacy Benefit Management (PBM) Transportation for Medicaid

    52. MAHAP General Session February 19, 2010 52 Carve Outs PBMs Used because Unique Network Codes and costs of drugs change weekly 99.9% of claims auto adjudicated Benefit Structures are challenging

    53. MAHAP General Session February 19, 2010 53 Carve Outs Formularies Step Formularies Take this medication before you take the more costly medication Open Formularies Patient can take whatever is prescribed, but the cost is different: $15 generic, $30 brand, $45 non-preferred brand

    54. MAHAP General Session February 19, 2010 54 Contact Kelly Partin Financial Managed Care Analyst (248) 615-7458 kpartin@botsford.org

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