for DR.SAMUELSON only!!!!
frguerradi
week_4_lecture.pptxEnrollment, Billing, Claims and Benefits Administration, Health Care Fraud and Abuse and Member Services
WEEK FOUR LECTURE
Enrollment and Billing in Commercial Health Plans
Eligibility in the commercial market may be thought of in three categories:
Eligibility in Employer Sponsored Group Benefits Plans
Eligibility changes based on life events
Individual eligibility
Employer sponsored coverage
Must be full time
Dependent coverage through employee
Must enroll during defined periods such as upon employment or annual open enrollment
Life Events
Life Events mean special periods of eligibility
Life Events are defined in several laws
The Employee Retirement Income Security Act (ERISA)
The Consolidated Omnibus Reconciliation Act (COBRA)
The Health Insurance Portability and Accountability Act (HIPAA)
The Newborn’s and Mothers’ Health Protection Act
The ACA
Examples of Life Events:
Losing employment means losing coverage
Marriage, divorce, or death of a spouse
Birth or adoption
Losing eligibility for coverage under COBRA
Individuals can only continue or obtain coverage during a defined period of time following a life event, and failure to do so means they lose eligibility
Individual Eligibility
Until 2014, individuals who are not eligible via Life Events and who do not have coverage usually must meet underwriting criteria, meaning free of any serious medical conditions
Some states have annual mandatory open enrollment periods when individuals who failed medical underwriting may obtain coverage from nonprofit plans, but coverage is poor and costly
After 2014, medical underwriting will no longer apply under the ACA, which is called guaranteed issue
ACA only requires guaranteed issue for life events and for one month per year, though states may expand that time period if they choose
Sources of Enrollment Data
Many sources of data, e.g.
Magnetic tapes
Direct electronic transmission
Paper – entered via scanning and OCR or manual entry
Direct entry by employer, broker, government agency
Received data often problematic, e.g.
Inconsistent HR systems at employer
Incorrect or missing information
Outdated elements (e.g., no longer employed, wrong address, etc.)
Enrollment function frequently outsourced or located where costs are low
HIPAA electronic standards exist for enrollment
Currently, only health plans are compelled to comply with them
HR 3590 calls for new processes and electronic interchange, including consumer access
After 2014, Exchanges will use them too
Beginning 2014, Exchanges will need to verify eligibility, incl. for subsidies
Billing
Enrollment data used to generate bills
To employer
To individuals
To agencies
To individuals and government beginning 2014 for subsidized coverage
Bills are for premiums for insured accounts, or administrative fees only (ASO) in self-funded accounts
Actual bills may be through automated electronic funds transfer (EFT), electronically transmitted only, or paper-based (but also have secure Internet lookup capability)
Some large employers self-bill, meaning they perform the calculation using their own internal data, which may or may not be consistent with data at the MCO
Because the risk of errors, enrollment and billing must be regularly reconciled
Enrollment and Billing in Medicare Advantage
Title XVIII of the Social Security Act is Health Insurance for the Aged and Disabled and made up of four parts:
Part A-inpatient hospital care, skilled nursing facility, hospice and home health care
Part B-Supplementary Medical Insurance Benefits-physicians’ services and other medical services and supplies
Part C-The Medicare Advantage Program-enrollment in private health plans
Part D-Prescription Drug Coverage.
Medicare is not completely free to the beneficiary and is funded through a combination of sources:
Part of the funding comes from a portion of the payroll taxes paid by workers and their employers;
Monthly premiums deducted from Social Security checks or direct billing; and
Premiums, coinsurance, co pays and deductibles paid by the Medicare beneficiary.
MA Eligibility
In order to enroll in Medicare, the individual must first make application for Medicare to the Social Security Administration (SSA). The SSA controls the enrollment for Social Security retirement benefits and enrollment for Medicare.
To enroll in a MA Plan, an individual must meet the following requirements:
Entitled to Medicare Part A and enrolled in Part B and must be entitled to Medicare Part A and Part B benefits as of the effective date of coverage under the plan;
Does not have End Stage Renal Disease (ESRD);
Permanently resides in the service area of the MA plan;
The individual or their legal representative completes an enrollment request;
Agrees to abide by the rules of the MA Plan;
Makes a valid enrollment request during an enrollment period; and
If requesting enrollment in a Special Needs Plan (SNP), the individual must meet the additional requirements for the SNP.
There are times when a Medicaid recipient also qualifies for Medicare.
The individual may receive assistance in paying Medicare premiums, deductibles, co-insurance and co pays through the state’s Medicare Savings Program.
In order to limit its liability for health care costs, the state Medicaid program may participate in the Medicare Buy-In program.
Election Periods and Enrollment Requests
Medicare eligible beneficiaries may enroll in an MA plan only at defined periods
The Annual Election Period (AEP);
The Initial Coverage Election Period (ICEP);
Open Enrollment Period for Institutionalized Individuals (OEPI); and
Special Election Periods (SEP).
The application for enrolling in a MA Plan is referred to as an “enrollment request.” This enrollment request (ER) must be:
Completed by the eligible individual or their legal representative; and
Provided to the MA Plan within the required time frames and during a valid enrollment period
Other means of enrollment include:
An optional Employer/Union Enrollment Request Mechanism;
Passive Enrollment by CMS; and
Group Enrollment for Employer or Union Sponsored Plans.
For new MA eligibles, CMS allows MA plans to offer a seamless MA enrollment for individuals enrolled in the organization’s commercial or Medicaid health plans at the time of the beneficiary’s conversion to Medicare
Claims Administration
Claims Administration is a core function of any payer
Considering their importance and breadth, the cost to perform this function is usually only about 10 – 12% of total admin spend
Automation has had a significant impact on efficiency and effectiveness of both
These are the functions that most consumers see, whether for good or ill
If good, we ignore and promptly forget about it
If ill, we are aggravated beyond belief and our attitude towards the MCO is long tainted
To those outside the MCO, the claims process is often the “face” of the MCO, particularly to the provider community.
To MCO business leaders, government agencies, and others within the health insurance industry, Claims is the source of information that allows the MCO to gauge and improve its business performance and improve the health care of its members.
As the modern claims capability continues to evolve, information management techniques will continue to create a place of greater prominence for the claims capability in the 21st century.
Managing the Claims Organization
Shared across the four claims capability core competencies are common, enterprise-wide objectives including:
Enabling the MCO to meet contractual obligations to employer groups, government agencies, members, and providers.
Ensuring timely benefits administration for enrolled members including the accurate application of cost sharing features, benefit limitations, maximums, and exclusions.
Administering medical management policies and medical necessity decisions.
Shared across the four claims capability core competencies are common, enterprise-wide objectives including:
Improving the healthcare of its members through the development and execution of care management plans.
Providing prompt and accurate customer service to members, brokers, employer groups, and providers.
Protecting financial liability by validating eligibility, avoiding duplicate and other inappropriate claims, ensuring accurate processing, administering other party liability programs, pursuing cost-containment activities related to known or specific financial leakage, and ensuring timely productivity to avoid processing penalties and interest payments.
Elements of Claims Complexity
Claims Auto Adjudication
All payers use transactional processing systems to automatically adjudicate claims
Auto adjudication allows approximately 85% of claims to be process for payment or denial without human intervention, and the percentage is still rising
Depends on careful population of certain files, dictionaries, fee schedules, code sets, etc that determine:
If a claim can be paid, and
How much should be paid
Governs the 7 core claims determinations
7 Core Claims Determinations
1.Determination of Eligibility & Liability
2.Coordination of Benefits (COB) and Other Party Liability (OPL
3.Benefits Administration
4. Application of Provider Payment Schedules
5. Resubmission
6. Adjustments & Appeals
7. Fraud & Abuse
Claims Quality Control
Quality control focuses on functions and processes from initial intake through preparation/staging and concludes with customer service, appeals, and renewal of the employer group or government contract
Upstream Quality: Processes and system files that govern and enable automatic and manual claims adjudication including:
Lines of business, groups, subgroups
Benefit plans, code sets
Eligibility and Other Party Liability records
Provider records and reimbursement rates
Authorizations
Downstream Quality: Errors within the claims department due to carelessness, unclear procedures, insufficient training, inattentive management
Definitions
Health Care Fraud occurs when someone misrepresents a fact related to health care services to receive - or increase – services, or reimbursement from a health plan or the government.
Health Care Abuse occurs when an activity takes advantage of the health care system but does not meet the legal definition of fraud or is not medically necessary
High Risk Areas for Health Care Fraud
Geographic- Miami and other Health Care Fraud Prevention and Enforcement Action Team (HEAT) cities.
High Risk Types- of health care fraud
Pharmacy
Hospitals
Durable Medical Equipment Suppliers (DME)
Physician Billing
Skilled Nursing Facilities
Home Health Agencies
Key Players
HHS OIG, CMS, DOJ, FBI, DEA, State DOI/AG
MIC, MAC, MEDIC, PSC, RAC, QIO, ZPICS
NHCAA, ACFE, NAIC, NADDI, HCCA
United States Sentencing Guidelines and OIG Compliance Programs
The United States Sentencing Guidelines contain compliance elements, which if followed place health care entities in an optimal position in the event they face a federal fraud charge.
The OIG Compliance Program Guidance contains the seven elements of compliance.
The strategy behind these guidelines is that if entities have effective compliance programs they will prevent fraud.
The Seven Elements of Compliance
Policies and procedures
Compliance Officer
Education and training
Effective communication
Enforce standards
Monitoring and auditing
Prompt corrective action
Role of Member Services and Consumer Affairs
Help members understand how to use the plan
Help resolve members’ problems or questions
Monitor and track the nature of member contacts
Allow members to express dissatisfaction with their care
Help members seek review of claims that have been denied or covered at a lower than expected level of benefits
Manage member problems with payments
Help address routine business issues
Member Services Operations
Location may be other than main offices
Considerations include:
Commercial real estate costs (leasing/purchasing)
Labor wage rates
Telecommunications and technology infrastructure
Availability of high school, community college, and (in some cases) college-educated CSR candidates
Availability of qualified customer interaction center management candidates
May be outsourced to third party
Special considerations for member services
Hours of availability
Real time availability vs. self-serve
Person-to-person voice vs. electronic communication
Non-English communications
Data Collection and Analysis
Satisfaction Data
Surveys
Consumer Assessment of Healthcare Providers and Systems (CAHPS®)
Healthcare Effectiveness Data and Information Set (HEDIS®)
New satisfaction reports may be required under reform, though new law primarily focuses on CAHPS and HEDIS
Direct mail campaigns
Trends Analysis
Random versus widespread problems
Automated tracking systems
Rules and Regulations for Formal Appeals
ACA created minimum required standards for appeals of a denial of coverage or a recession
ERISA standards may apply
States also typically have minimum standards
ACA created a federal mechanism for appeals in situations where neither ERISA or state requirements apply
Two levels of review: internal and external
And there are always the courts…
Basic Requirements for Internal Review of Formal Appeals
Member must file an appeal of the initial denial within 180 days of notification, or lose the right to file
Reviewers
Must not have been involved in initial denial
Must not be a subordinate of person who made initial denial
Must not take initial decision into account when reviewing the appeal
Urgent pre-authorization appeals to be reviewed in 72 hours or less
Pre-authorization appeals must be resolved within 30 days
Claims denials (i.e., post-service) must be resolved within 60 days
Additional time may be allowed under certain circumstances such as the need for additional information, but member can refuse
Member can demand that both internal and external review be conducted simultaneously
Decision to overturn a denial is binding on the plan
Basic Requirements for External Review of Formal Appeals (cont.)
Review conducted by an Independent Review Organization (IRO)
IRO is completely independent
IROs must be accredited
Must be more than one IRO that can review appeals
Member must request external review within 4 months of being informed that internal review upheld the denial
No minimal dollar amount for an appeal
Plan bears the cost
Must cost the member no more than a $25 fee
Cases randomly assigned IROs
Urgent situations to be reviewed in 72 hours or less
Non-urgent reviews must be resolved within 45 days
Decision is binding
