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How to Safely Navigate the River of CashLeadingAge NY Financial Managers ConferenceAugust 2016Navigation Considerations Know your river Maneuver around obstacles Strainers – enrollment and authorizations Sweepers – audits and insurance verification Eddies – payor requirements and collections Hydraulics – appeals and denial management Sandbars – NAMI collection and self pay Thorough trip planningPage 21
Know your river looks can be deceivingPage 3Medicare Advantage Since 2010 national enrollment increased by 30% July 2016: 1.28 million NY enrollees (38% penetration) 15 counties with 25% penetrationo Clinton, Dutchess, Essex, Franklin, Nassau, Orange, Otsego,Putnam, Rockland, St. Lawrence, Suffolk, Sullivan, Tompkins,Ulster and Westchester 11 counties with 50% penetrationo Bronx, Erie, Genesee, Livingston, Monroe, Niagara, Ontario,Orleans, Wayne, Wyoming and tate-CountyPenetration-2016-07.html?DLPage 1&DLEntries 10&DLSort 1&DLSortDir descendingPage 42
New York Medicare Advantage (July Page 1&DLEntries 10&DLSort 1&DLSortDir descending# of Counties# of Contracts and Plans16100 - 10929110 - 12417125 - 1497150 - 1993200 Page 5Medicare Advantage I-SNP I-SNP Institutional Special Needs Plan Restricts enrollment to Medicare Advantage eligibles who for 90 days have had or are expected to need SNF/NF, ICF/MR orinpatient psychiatric facility services Provides extra care coordination and preventive servicesbenefits in addition to regular Medicare Advantage planbenefitso January 2016 UHC blocked by NYS Attorney General fromrequiring some SNFs in its commercial-plan provider networkto join the I-SNP networkPage 63
New York I-SNP (July 2016)# of Plans# of ReportedEnrollees27234,029 Affinity, Agewell NY, Alphacare, Amida, Atlantis, CatholicSpecial Needs, Centerlight, Centers Plan, Cuatro, Elderplan,Elderserve, Empire Health Choice, Fallon Health Weinberg,Group Health Inc, Guildnet, HIP, Healthfirst, Humana, IHA,Liberty Health, MetroPlus, Quality, Senior Whole Health, NYSCatholic Health Plan, UHC, VNS Choice and NP-ComprehensiveReport-2016-07.html?DLPage 1&DLEntries 10&DLSort 1&DLSortDir descendingPage 7Medicaid Managed Care MLTC – Managed Long Term Care Plan Long term care and home care services Medicare/Medicare Advantage stays in place Mandatory for dual eligibles MA – Medicaid Advantage Includes Medicare services but Medicaid coverage without LTC MMCP – Medicaid Managed Care Plan (mainstream) Managed care version of Medicaid and covers LTC Mandatory for most Medicaid recipients – dual eligibles areexcludedPage 84
Medicaid Managed Care MAP – Medicaid Advantage Plus Traditional insurance model for age 18 , intensive casemanagement model If required to enroll in MLTC may choose to enroll in aMAP Must enroll in the plan’s Medicare product Limited plans across the statePage 9Medicaid Managed Care FIDA (Fully Integrated Dual Advantage) Both Medicare and Medicaid services, including Part D Rx Builds upon existing MLTC program Bronx, Kings, Nassau, New York, Queens, Richmond, Suffolk andWestchester (delayed roll-out to Suffolk and Westchester) Passive enrollment suspended December 2015 May 2016 enrollment dropped to 5,370 FIDA-IDD (Intellectual and Developmental Disabilities) Partnership with NYSDOH and OPWDD for dual-eligible enrollees Demo slated to run through December 2020 Bronx, Kings, Nassau, New York, Queens, Richmond, Rockland,Suffolk and WestchesterPage 105
Medicaid Managed Care HARP – Health and Recovery Plan Specialized integrated product line for people with significantbehavioral health needs Eligible based on utilization or functional impairment Must be insured only by Medicaid and eligible for Medicaidmanaged care What HARP’s do:o Manage Medicaid services for people who need themo Manage and enhanced benefit package of Home and Community-Based Services (HCBS)o Provide enhanced care management to help coordinate all physicalhealth, behavioral health and non-Medicaid support needsPage 11Medicaid Managed Care PACE(Programs of All-Inclusive Care of the Elderly) Provides a comprehensive system of health care services formembers age 55 and older who are otherwise eligible fornursing home admission Both Medicare and Medicaid pay for PACE services (on a fullcapitated basis) PACE members are required to use PACE physicians and aninterdisciplinary team develops care plans and provides ongoing care management PACE is responsible for directly providing or arranging allprimary, inpatient hospital and long-term care services requiredby a PACE memberPage 126
Managed Care OptionsOptions if ONLY have Medicare OR MedicaidInsuranceFee for ServiceManaged Care ModelHaveMEDICAREonlyRegular Medicare Original Medicare Part D plan Medigap (optional)Medicare Advantage plan usuallycovers Part D Voluntary but 30% of Medicarebeneficiaries join Pros: Cheaper than a Medigappremium and controls other out-ofpocket costs Cons: Must be in-network and obtainplan approvalHaveMEDICAIDonlyRegular Medicaid – only for peopleexcluded or exempt from managedcare (spend down, transitioning toManaged Care, etc.)Medicaid Managed Care Mandatory for non-dual eligibles Covers primary, acute and long termcareHARPPage 13Managed Care OptionsOptions for Dual EligiblesInsuranceFee for ServiceManaged Care ModelIF DON’T NEED LONG TERM CARE SERVICESMedicaid &Medicare(dualeligibles)Medicare Original Medicare Part D plan Medigap (optional)MedicaidMedicaid Advantage – voluntary. CombinesMedicare Advantage with Medicaid managed careplan in ONE. If in Medicaid Advantage can not joinan MLTC.IF NEED LONG TERM CARE SERVICESMedicare Original Medicare Part D plan Medigap (optional)Medicaid Medicaid card – onlyfor primary, acute careMLTC – Mandatory for most dual eligibles. Primary& acute care thru Medicare, with CHOICE ofOriginal Medicare/Part D or Medicare Advantageplus Medicaid through MLTCMedicaid Advantage Plus (MAP) or PACE orFIDA or FIDA-IDD – voluntary option replaces allMedicare, Medicaid and MLTC coverage in ONEplan (full capitation)Page 147
Medicaid Managed Care – NY State July 2016 Managed Care Enrollment MLTC PACE – 9 Plans over 12 counties; 5,512 enrollees MLTC Partial Cap – 32 Plans over all counties;157,088 enrollees Medicaid Advantage (declining enrollment upstate)o 7 Plans in 35 counties; 3,276 enrolleeso 7 Plans in NYC; 5,323 enrollees Medicaid Advantage Plus (increasing enrollment)o 4 Plans in 7 counties; 325 enrolleeso 7 Plans in NYC; 5,638 enrolleeshttp://www.health.ny.gov/health care/managed care/reports/enrollment/monthly/Page 15Medicaid Managed Care – NY State April 2016 Managed Care Enrollment Mainstream Medicaid Managed Care and NYSOHo 19 plans; 4,436,994 enrolleesoHARP (increasing enrollment)o 13 plans; 47,707 enrolleeshttp://www.health.ny.gov/health care/managed care/reports/enrollment/monthly/Page 168
MLTC Partial Capitation Examples – July 2016ElderplanDutchess – 20Rockland – 67Nassau – 246Suffolk – 202New York – 9,937Sullivan – 5Orange – 52Ulster – 5Putnam – 8Westchester – 90TOTAL 11,132Page 17MLTC Partial Capitation Examples – July 2016GuildnetUnited HealthCareNassau – 1,884Albany – 44New York – 11,994Broome – 133Oneida – 70Suffolk – 2,336Erie – 68Onondaga – 144Westchester – 477Monroe – 233Rockland – 32TOTAL – 16,691New York – 1,640TOTAL 2,339Page 189
MLTC Partial Capitation Examples – July 2016WellCareVNA HomeCare OptionsAlbany – 47Rockland – 198Albany – 129Onondaga – 388Erie – 198Suffolk – 41Chautauqua – 108Oswego – 81Nassau – 77Ulster – 110Erie - 119St Lawrence – 98New York – 5,480Westchester –69Fulton – 106Saratoga – 100Jefferson – 83Schenectady –144Orange – 203TOTAL 6,423Monroe – 30134 counties (less than 80 each) – 827TOTAL 2,484Page 19Medicaid Advantage Plus – July 4)NYC(1,059)NYC(477)Schenectady(18)NYC(56)Page 2010
HARP – April 2016AffinityCDPHPExcellusHealth urCare8,42446710,0481892,844234Page 21Helpful Resources Transition of Nursing Home Populations and Benefits to MedicaidManaged Care January 2015 https://www.health.ny.gov/health care/medicaid/redesign/docs/201501-22 nh transition rev.pdf Transition of Nursing Home Populations and Benefits to MedicaidManaged Care Frequently Asked Questions January 2015 https://www.health.ny.gov/health care/medicaid/redesign/formatted nh faq part a.htm Office of Health Insurance Programs Transition of Nursing HomeBenefit and Population into Managed Care February 2015Implementation https://www.health.ny.gov/health care/medicaid/redesign/docs/nursing home transition final policy paper.pdfPage 2211
Helpful Resources Transition of Nursing Home Populations and Benefits to MedicaidManaged Care Frequently Asked Questions March 2015 36-AC541D3B78EE97E6FFBF/showMeta/0/ Transition of Nursing Home Populations and Benefits to MedicaidManaged Care Frequently Asked Questions Part 2 March 2015 AA-CF4B1617BFF7257C1CB7/showMeta/0/ Transition of Nursing Home Populations and Benefits to MedicaidManaged Care Frequently Asked Questions March 2015(Updated) email ahagen@bonadio.comPage 23Helpful Resources Transition of Nursing Home Populations and Benefits to MedicaidManaged Care Frequently Asked Questions October 2015(Consolidated) dated.pdf Transition of Nursing Home Populations and Benefits to MedicaidManaged Care Frequently Asked Questions Revised January2016 http://www.health.ny.gov/health care/medicaid/redesign/docs/2016jan rev nh transition faqs.pdfPage 2412
Helpful Resources FIDA Resources: updates, notices, policy documents, outreachand education, FAQs, webinars http://www.health.ny.gov/health care/medicaid/redesign/mrt 101.htm FIDA Open Questions FAQ April 2016 http://www.leadingageny.org/?LinkServID 33305257-9D82-8CD60185A0626F0B1BEAPage 25Rates Medicare Advantage Negotiated per diem rates orMedicare rate Commercial Plans Negotiated rateso “Pay lesser of daily rate or billed UCC rate” Medicaid Managed Care Rate – 3 year current FFS (benchmark) rate or negotiated rate Must be increased if it falls below current benchmark rate If previously negotiated rate: pay benchmark during transitionunless other arrangement is agreed toPage 2613
Rates Medicaid Managed Care Are you working with MLTC’s to set future rates?o What is your value?o What value initiatives are they interested in?Page 27Bed Hold Methodology Medicaid Managed Care Bed hold methodology – unless otherwise negotiated, MCO requiredto follow current Federal/State Medicaid bed hold regulations (CFR483.12 and 10YCRR 415.8 and 18NYCRR 505.9) – priorauthorization may be requiredReimbursementLimitationsLOA temporary hospitalization /health care professional therapeutic50%Not to exceed 14 days inany 12 month periodLOA non-hospitalization / health careprofessional therapeutic95%Not to exceed 10 days inany 12 month periodMust have been resident for at least 30 days and unit to which recipient will return has avacancy of no more than 5%If plans not paying – contact Vallencia Lloyd (Mainstream) vallencia.lloyd@health.ny.govORMark Kissinger (MLTC) mark.kissinger@health.ny.govPage 2814
Billing / Payment Cycle Medicare Advantage and Commercial Billing cycle – monthly Payor specific payment cycle andremittance retrieval options BCBS switch to InstaMed Medicaid Managed Care Billing Cycle –at least every 2 weeks (bi-weekly) or twice a montho Not generally mentioned in provider/billing manuals – don’t makeassumptionso Does billing department needs to change current process? Payor specific payment cycle and remittance retrieval options Medicaid Weekly payment cyclePage 29Maneuver Around ObstaclesPage 3015
Strainers Underwater obstacles you get pushed into by the currentPage 31Strainers AKA Enrollment Medicare Advantage and Commercial plans Enrollment changes not limited to open enrollment periodsalthough many changes occur then Families often not good at communicating changes Facilities don’t routinely verify coveragePage 3216
Strainers AKA Enrollment New Eligible/Not in a Medicaid MCO Coming from home to NH (long term): Apply for Medicaid following allcurrent regulations, including physician recommendation, PASRRprocess, Patient Review Instrument (PRI), etc. LDSS has 45 days to complete determination for long term Medicaideligibility Once approved and any penalty period has elapsed and NAMIamount is identified resident has 60 days to choose an MCO NY Medicaid Choice will assist in education, plan selection andenrollment (in a plan with which the nursing home contracts) Auto enrolled if not select MLTC: No lock-in so enrollment may changePage 33Strainers AKA Enrollment Enrollment – Already Medicaid MCO Enrolled MCO must authorize all long term placements and pay the NHwhile long term eligibility is being conducted by LDDS NH and MCO assist with submitting documentation to LDDS(send MCO authorization with 3559) Member has 90 days from date long term placement isdetermined to submit the application for coverage of long termcustodial placement to the LDSS LDSS will notify MCO, enrollee and NHo If eligible – MCO keeps paying NH and NAMI is collectedo If ineligible – MCO recoup payment from NH and coordinate safedischarge into the communityPage 3417
Strainers AKA Enrollment How do you track open enrollment changes? How will you track initial Medicaid managed care enrollments? How will you track enrollment changes? “The provider must check eligibility and enrollment status at the time ofservice or weekly for NH services for billing purposes” FAQ March 2015 Develop policies and procedures and provide staff training Failure to track may result in untimely billing to the correct payor 834 electronic enrollment files or will payor provide a roster? Enhanced communication with families?Page 35Strainers AKA Admission Authorizations Medicare Advantage and Commercial Authorization is generally requiredo Revenue Code level or Level of Care Medicaid Managed Care If enrolled in a plan, MCO must authorizeall long term care placements and willpay the nursing home while long termeligibility is being conducted by LDSS Authorization is generally required Responsibility for initiating authorizationand timing is payor specific Ultimately SNF bears the riskPage 3618
Strainers AKA Authorization Requirements UAS-NY assessment completed by Medicaid MCO – required whenindividual enrolls in a plan and every 6 months thereafter or whensignificant change in condition occurs – in person (per MLTC Policy16.01: UAS-NY Assessment Requirements) MCO required to compare the UAS-NY assessment needs with the MDSassessments conducted by NH and consider both when authorizingservices, equipment and supplies The care plan, MDS, UAS-NY, medical record and input from caremanagement team will provide the MCO with the information needed forauthorization of services Although reassessment using UAS-NY is required at above schedule,MCOs may authorize for shorter time periodso daily, several times each week, weekly and monthly Medicaid MCO may require authorization for bed holdsPage 37Strainers AKA Admission Authorizations UAS-NY Considerations MCO is using your data to make authorization decisionso How well are you representing your data and your care? Who is working with payer Case Manager?o One or several employees?o Is the presentation the same by all? UAS-NY and MDS don’t cross-walk perfectlyo Are you documenting in a manner that supports both sets ofrequirements?Page 3819
Strainers AKA Authorization Requirements All Managed Care Always verify if an authorization is needed and for whatservices – admissions, routine services, supplies,equipment, etc.o If you perform and bill for x-rays do you need an authorization? Payors may require authorizations for some plans but nototherso Specific plan determines authorization requirements Document contact person and telephone numbers forfuture authorization extensions and reassessmentsPage 39Strainers AKA Authorization Requirements All Managed Care When is re-authorization required? What form? Portal orpaper? Can current staff handle the increase in work due toMedicaid Managed Care?o Case management vs floor staff vs billing staff vs newposition? Coordination between billing and prior authorization staffo When/how/does billing get the authorization number?Page 4020
Sweepers Overhanging obstaclesPage 41Sweepers AKA Audits OMIG 2016 – 2017 Work Plan ALP Resident Care and Needs Goods/Services Included in ALP Rate Base Year Audits Eligibility for Bed Holds Capital Costs MDS (7/1/14 – 6/30/15 rates) Notice of Rate Changes (Rollovers) Rate Appeals Coordination of Benefits Social ADC MLTC Eligibility Home Health Services, Spend Downs, Medicare Maximization Compliance Program On-Site ReviewPage 4221
Sweeper AKA Audits Do you have revenue cycle policies and procedures? Include: Admissions, Business Office, Billing, MDS, Therapy,Medical Records, Medical/Professional Services, Nursing,Materials Managemento Insurance Verificationo Payment Postingo Prior Authorizationso NAMI verificationo MDS Completion/Submissiono Resident Trusto Therapy documentation/coding/chargeso Bed Holdo Charge Entryo Diagnosis Codeso Consolidated Billingo Claims SubmissionPage 43Sweepers AKA Audits When were policies and procedures last updated? Software/vendor changes System updates Clearinghouse implemented New positions that changed processesPage 4422
Sweepers AKA Audits Do you have a training program? New hires and routine refresher trainingo Regular cycle and as needed Must be documentedo Staff sign off on skills sheeto Meeting minuteso Attendance sign-inPage 45Sweepers AKA Audits Do you conduct internal reviews? Credit Balances – All payerso Review and process at least monthly for a quick/easy reviewo Quarterly Medicare Credit Balance Report Denials for all payerso Rotate focus on a new payor throughout the yearo Utilize electronic reports Demand Bills requested by residento Hold self pay billing Medicaid Managed CarePage 4623
Sweepers AKA Insurance Verification Medicare, Medicare Advantage Plan, Medicare Part D,Supplemental Plans, Medigap, Commercial Plans, Medicaid,Medicaid Managed Care, Medicaid Long Term Care, HARP Dual Eligible with original Medicare, Medicare Part D, Medigapand MLTC will have 5 insurance cards Medicaid Managed Care Internal Considerations Provider must check eligibility at the time of service and before billingo Currently may not be checking eligibility before billing Medicaido Is this going to be a new process?o Will you do it for all payors?o Who is going to do it?o What resources will they use?Page 47Sweepers AKA Insurance Verification Medicare FISS/Connex Check for each resident – not just Medicare Part A admissions Payor websites or phone calls to each insurance Clearinghouse insurance verification portal Batch eligibility verification (271 / 271 files) Prior to billing submit 270 file for eligibility verification via clearinghouse Possible: submit excel spreadsheet to clearinghouse if billing systemcan’t create a 270 file ePACES / Plan Rosters Look at eligibility and Restriction/Exemption codes (institutionalMedicaid, spend down)Page 4824
Page 49Sweepers AKA Insurance Verification Avoid being swept into the river Staff training Identify type of coverage (MA, MLTC, Dual Advantage, MAP,etc.) AND plan Document every call/contact in your billing system Complete verification before admission and billing Utilize technology to save timePage 5025
Eddy Water rushes around an obstacle and forms a whirlpoolPage 51Eddy AKA Payor Requirements Revenue Code / Level of Care Billing Rate Claim Format Timely Filing NOMNCPage 5226
Eddy AKA Revenue Code / Level of Care Medicare Advantage and Commercial Billing formats may vary Code properly to get the revenue you are entitled toRevenueCodeExcellus MedicareAdvantage andCommercialUHC EverCareMVP191Skilled NursingLevel ILevel A – ContinuingCare199Level Ia192Sub-acute TherapyLevel IILevel B – Low Rehab193Sub-acuteRehabilitationLevel III – IntensiveService DeliveryLevel C – HighRehab194Level D – MedicallyComplexPage 53Eddy AKA Revenue Code Medicaid Managed Care Uniform billing codes addressed in budget Law requires standard billing codes by January 1, 2016DescriptionFidelis Care at HomeRevenue CodeHealthfirst RevenueCodeBed Hold – TemporaryHospitalization01850185Bed Hold – Therapeutic LOA01830183Bed Hold – Other Therapeutic LOA0189N/ARoom and Board AncillaryServices0190, 0191, 0192, 01930100 (all inclusive custodial& respite)Room and Board Only0190, 0191, 0192, 01930100 (all inclusive custodial& respite)Page 5427
Eddy AKA Rate What rate should be on claim? Medicare or Medicaid Rate Negotiated Per Diem UCC (Usual and Customary Charge) Watch out for “Pays lesser of daily rate or billed UCC rate”Page 55Eddy AKA Claim Format Every new format creates added work Set up like another payor or plan? Which revenue codes? What rate? Which modifiers? Itemized or just R&B? Excluded services?Page 5628
Eddy AKA Claim Format Medicaid Managed Care Claim format may be similar to Medicaid format because ratecode is required Claim format may be similar to HMO because authorizationnumber is required Look at each plan and determine if a new claim format needsto be built Requires testing Maintain examples of clean claims for various bill types andservice types for each payor and plan in your billing officePage 57Eddy AKA Timely Filing Know timely filing requirements for each payor Most payors have a 90 day timely filing requirement Contract negotiations may extend this Bill at least monthly – no later than the 15th Bill as often as payor will allow Maximize billing and payment cycle For Example: Medicaid Cycleo Start date Thursday, 7/7/16o End date Wednesday, 7/13/16o Check date Monday, 7/18/16 (2 business days after end date)o Check release date Wednesday, 8/3/16 (3 weeks after end date)Page 5829
Eddy AKA NOMNC Does MLTC payer require a denial from Part A? Results in significant slow down in revenue cycle Will payer accept a NOMNC in lieu of a Part A denial? Develop internal process for issuance of NOMNC Submit copy of NOMNC instead of Part A denialPage 59Eddy AKA Collections Keep all claims alive with follow up Document every submission, mailing, phone call, etc. No more than 30 - 45 days between follow up attempts Verify receipt of claim – acceptance reports, fax confirmation,registered mail Utilize billing system collections moduleo If none – write follow up on calendar Prioritize follow up by large dollar and nearing timely filing Group calls to payor to save being on holdPage 6030
Hydraulics Water circulates on top of itself often at the base of a waterfall Can be fatal!Page 61Hydraulics AKA Denials Per AMA 1.38% – 5.07% of claims are denied on 1stsubmission Aetna – 6.00% UHC – 4.30% Cigna – 3.80% Medicare – 2.30% Need to work electronic rejection/acceptance reports Must review 999 and 277CAo 999 confirms that a file was received. However, the 999 includesadditional information about whether the received transaction haderrors. Accepted (A), Rejected (R), Accepted with errors (E)o 277CA acknowledges all accepted or rejected claims in the file Must work payor denials – review remittancesPage 6231
Hydraulics AKA Denials Industry shift toward managed care requires SNF to focus ondenial management Denial management is “old news” to physicians and hospitals Long ago addressed in their billing systems and processes (paymentposting and reporting) SNF billing systems and SNF process deficiencies Many billing systems don’t capture payment codes Many billing systems can’t generate denial management reports Minimal use of clearinghouses and available denial-related reports Many SNFs don’t post zero payments Most SNFs do not have a robust denial management program Consider additional report writing add-on software or programmingPage 63Hydraulics AKA Denials Cost to re-work a claimStaff time 10.67Supplies 1.50Interest 1.75Overhead 1.00TOTAL 14.92 Key Performance Indicators (KPIs): % of denied claims 5% % of EDI denied claims 1% % of paid after 1st appeal 75% Lag time to work denial 5 daysPage 6432
Hydraulics AKA Retro-Denial Process Track by payor Track documentationClaimBilled andPaidWin Lose ORGive UpTryingdeficiencies (makeimprovements goingforward)RecordsRequested Learn your weaknesses Therapy minutediscrepancy ADL documentation Submit summary pageFollowAppealProcessRecordsNotSupportRUG –PaymentRetractedwith records that showshow/where RUG/level issupported Perform documentationaudit and CDI projectPage 65Hydraulics AKA AppealsPayor and PlanAppeals/Disputes/Reconsiderations(on-line Provider Manuals)Payor OneMedical necessity appeal - Submit within 60 daysAdministrative denial reconsideration (timely filing, co-insurance, eligibility,lacking pre-auth, other errors on claim, underpayments) – Submit within 60daysTimely filing – penalty of up to 25% may be imposedPayor TwoTimely filing, incidental procedures, bundling, unlisted procedure codes, noncovered, etc. – Submit within 6 years of the date of denialPayor ThreeMCare and MCaidAdvantage PlansDisputes resulting from claim adjustments or denials:Standard reconsideration request – denial of payment or medical necessity –per contractPayor ThreeMedicaid MLTCDisputes resulting from claim adjustments or denials:Standard reconsideration request – denial of payment or medical necessity –per contractRequest for denial of payment due to claim coding – Submit within 90 daysRequest for denial of payment due to no authorization – Submit within 90 daysPage 6633
Hydraulics AKA Appeals Know each payors appeal process for each type of appeal Filing time limits (60, 90, per contract) Payment discount for timely filing appeal Specific forms Review your process for each type of appeal Who gathers the necessary documents? Who submits? Who monitors status? Are outcomes shared with all?o Are you learning from denied appeals?Page 67Sandbars Raised area of sand that is easy to get stuck onPage 6834
Sandbars AKA NAMI Collection Estimate at admission and attempt to collect Medicaid Managed Care Initial implementation shifts responsibility to MCO and MCOmay delegate it to NH or other entityo Should be outlined/agreed to during contractingo Make sure you have an internal process in place if agreement isdifferent than your current normo Long term plan – State or designee will assume financial andoperational responsibility to distribute NAMI and collect NAMIincomePage 69Sandbars AKA NAMI Collection Two important questions Who manages Social Security and other income? Does NH manage a resident fund of PNA money? If NH is rep pay it will never be free from NAMI responsibility Develop a spreadsheet to track 1,000 income 1,000 incomeResident 1,000NH rep payee 600Plan collects fromresident 950Plan collects fromresident 400 Resident give NH 50PNA (or keep) Plan pay NH 950 NH keep 50 PNA NH keep 550 of NAMI Plan pay NH 400Page 7035
Sandbars AKA Self Pay Pre-bill Many NH not pre-bill on new admissions if monthly statementsalready gone out Need a dedicated collections representative or allocate timefor biller to follow up Must make phone calls Extended work hours for collections representative Evenings and Saturday On-site near lobby Be convenientPage 71Sandbars AKA Resident Fund and Direct DepositManagement Resident Fund Management & Direct Deposit Management Direct Deposit Automated care cost payments and resident allowanceretention Direct debits from family member accounts at any bank to payfor care Automatic return of direct deposits when a resident expires ortransferso National Datacare Corporationo Built into some EMR/Billing SystemsPage 7236
Thorough Trip PlanningReview duties, resources and processes among financial andclinical staff to enhance efficiencies, performance andoutcomesPage 73Assignment of Billing Staff Small homes: one biller may not be enough Current silo structure may become ineffective Medicaid Managed Careo May be too much work for one person to handleo Medicare Advantage/Commercial blurring into MedicaidManaged Care Consider alpha-split or shift additional FTE to Medicaidmanaged care billingPage 7437
Billing Calendar Make modifications to billing calendar for new billing cyclesPage 75Estimated Per Transaction TPOTENTIALSAVINGSOPPORTUNITIESCLAIM SUBMISSION (837 I /P)ManualElectronic 2.58 0.54 2.04ELIGIBILITY and BENEFITVERIFICATION (270/271)ManualElectronic 3.55 0.16 3.39PRIOR AUTHORIZATION (278)ManualElectronic 18.53 5.20 13.33CLAIM STATUS (276/277)ManualElectronic 2.25 0.23 2.02Page 7638
Estimated Per Transaction TPOTENTIALSAVINGSOPPORTUNITIESCLAIM PAYMENT (835)ManualElectronic 1.83 0.30 1.53REMITTANCE ADVICE (835)ManualElectronic 1.83 0.30 1.53Sources: CAQH, Milliman, Inc. (2013)Page 77Clearinghouse Vendor that serves a
New York -9,937 Sullivan -5 Orange -52 Ulster-5 Putnam-8 Westchester -90 TOTAL11,132 Page 18 MLTC Partial Capitation Examples -July 2016 Guildnet Nassau -1,884 New York -11,994 Suffolk-2,336 Westchester -477 TOTAL -16,691 United HealthCare Albany -44 New York -1,640 Broome -133 Oneida-70 Erie-68 Onondaga -144
