Making Every Dollar Count: Effective Strategies for Using Ryan White CARE Act Funds and Third Party

1
Making Every Dollar CountEffective Strategies
for Using Ryan White CARE Act Funds and Third
Party Reimbursement in an Era of Diminished
Resources
2
Julia Hidalgo, ScD, MSW, MPHPositive
Outcomes, Inc.Harwood MDwww.positiveoutcomes.ne
tjulia.hidalgo_at_positiveoutcomes.net(443) 203 -
0305
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• Planning Committee
• Aubrey Arnold
• Gayle Corso
• John Eaton
• Theresa Fiano
• William Green
• Deidre Kelly
• Syd McCallister
• AHCA
• Heidi Fox

• HRSA HAB Project Officers
• Johanne Messore
• Yukiko Tani
• TPR Trainers
• Curt Degenfelder
• Marilyn Massick
• Michael Taylor

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Ground Rules

• I do not represent HRSA, CMS, or AHCA
• Let me know if you do not understand
• We can share our feelings at the end of each
  section
• You will be rewarded for staying awake
• Shut off your electronic devices
• A 15 minute break means 15 minutes!

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Overview of Todays Session

• Overview of financing, third party reimbursement
  (TPR), and eligibility determination
• Train the trainer approach
• Materials on the POI website
• Please follow-up by email with additional
  questions
• Topics covered
• HRSAs payer of last resort (PLR) policies
• Changes on the horizon that make it increasingly
  important for CARE Act grantees and subgrantees
  to address financing and eligibility
  determination issues
• TPR
• Participating in Florida Medicaid, commercial
  insurance, and managed care systems
• Estimating your programs costs
• Marketing your programs services
• Eligibility determination

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What is third party reimbursement?
TPR is receiving payment from a source other than
the patient for services provided to patients by
a provider. This other source is the third
party.
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CARE Act Payer of Last Resort Policies
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CARE Act Has Three Principal Fiscal Requirements

• Matching Funds
• Title II Match
• ADAP Match
• ADAP Supplemental Match
• Maintenance of Effort (MOE)
• Payer of Last Resort (PLR)

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Three CARE Act Fiscal Requirements By Title and
Part F
DRP Dental Reimbursement Program
10
Title II Matching Fund Requirement

• Introduced in the 1990 CARE Act authorization
• State Title II programs must match a percentage
  of Federal funds received under the CARE Act with
  State funds or expenditures
• Applies only to Title II grantees with gt 1 of
  the US AIDS cases reported for the two most
  recent fiscal years
• The match rate started at 16.66 in 1990 and
  increased to 33.33 in 1994
• The required matching fund rate has not been
  increased since the CARE Act 1990 authorization
• Requirement cannot be waived if a State is unable
  to maintain its match rate

11
Maintenance of Effort (MOE) Requirement

• Introduced in the 1996 CARE Act reauthorization
• Grantees are required to maintain a level of HIV
  expenditures for services at an amount that is
  equal to the levels of such expenditures for the
  preceding year
• The MOE provision under Title I, II, III,
  states that the Secretary shall not make a grant
  under this subsection if doing so would result in
  a reduction of State funding allocated for such
  purposes
• Federal funding can be decreased but not directly
  due to a reduction in other Federal funds,
  including reduction in CARE Act funds received by
  Title I, II, or AETC grantees

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HAB PLR Policies

• Are CARE Act grantees or sub-grantees required to
  bill?
• If you provide services that are eligible for TPR
  and you charge anyone, you must have a system to
  bill and collect from third parties
• You must identify potential TPR sources for each
  client, refer them for eligibility determination,
  set up billing systems, bill all available TPR
  sources, and negotiate the best reimbursement
  rates possible
• While Medicaid eligibility is pending you may use
  grant dollars but you must bill retroactively
• Pay and chase
• Does HAB support the reduction of a grant award
  to their contractors due to increased TPR?
• No, HRSA discourages this preferring that you
  use the revenue to expand and/or enhance HIV
  services

13
Who is the payer of last resort (PLR)?

• HAB considers the CARE Act to be the payer of
  last resort
• Services that must be reimbursed by any private
  or public payers should be determined before CARE
  Act funds are used to pay for care
• It is unclear which CARE Act Title should be
  considered the payer of last resort among CARE
  Act programs

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HAB PLR Policies

• Must an agency credit their HIV units budget for
  TPR or can they retain the funds?
• Your organization must report the amount of the
  reimbursements to the HIV/AIDS unit and to return
  or credit those funds to the HIV program
• How can funds received from TPR be used?
• The funds must be used to pay for HIV services to
  the populations
• Since TP payment is typically less than submitted
  charges, should the grantee or contractor bill
  for their actual costs?
• CARE Act funds cannot be used to balance bill
• Try to negotiate the best possible rate with
  insurers

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HAB PLR Policies

• How can our program become a Medicaid provider?
• Check the State Medicaid website or contact the
  State Medicaid Program directly
• Help can also be obtained from CMSs Regional
  Office www.cms.gov/about/regions
• Can CARE Act funds be used to pay to prepare to
  become a Medicaid provider?
• Yes, capacity development funds may be used for
  this purpose
• The Title I Planning Council must allocate
  capacity development funds

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HAB PLR Policies

• What must we do to meet the qualifications to be
  a provider if our employees do not meet Medicaid
  credential requirements and we provide Medicaid
  covered services?
• If you do not charge for the covered service or
  seek TPR, there is a waiver provision
• Otherwise, careful attention should be paid to
  staffing a program with quality of care and
  reimbursement implications in mind
• Your program should evaluate the costs and
  benefits of adjusting your staff mix over time to
  assess if staffing changes would be beneficial in
  the long term to ensure quality of care

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HAB PLR Policies

• Can a grantee require a contractor to become a
  Medicaid provider even if the service provided is
  not covered by Medicaid?
• No
• If a client is enrolled in Medicaid, can CARE Act
  funds be used to pay for case management?
• If your State Medicaid Plan covers the type of
  case management that you provide, Medicaid should
  pay for those services
• To find out if case management is covered see
  www.cms.gov/medicaid/tollfree.asp
• To obtain information about your States State
  Medicaid Plan see www.cms.gov/medicaid/stateplans
  /map/asp
• If the case management services provided by your
  agency are not covered, then the services may be
  paid for using CARE Act funds

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Sliding Fee Scale

• CARE ACT specifies the following sliding fee
  scale for clients with an income
• lt 100 of FPL may not be charged for service
  provided under the grant
• gt 100 of FPL must be charged for services based
  on a schedule that is available to the public
• gt 100 and lt 200 of FPL, the provider will not,
  for any calendar year, impose charges in an
  amount exceeding 5 of the clients annual gross
  income
• gt 200 and lt 300 of FPL, the provider will not,
  for any calendar year, impose charges in an
  amount exceeding 7 of the clients annual gross
  income
• gt 300 of FPL, the provider will not, for any
  calendar year, impose charges in an amount
  exceeding 10 of the clients annual gross income

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Sliding Fee Scale

• If a CARE ACT grantee or subgrantee charges for
  its services, it must do so on a sliding fee
  scale or a schedule available to the public
• CARE ACT grantees or subgrantees may use their
  discretion, in the case of clients subject to a
  charge, to assess the amount of the charge,
  including imposing only a nominal charge for the
  provision of service
• The grantee or subgrantee must take into
  consideration the medical expenses of clients in
  assessing the amount of the charge

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Challenges to Applying a Sliding Fee Scale

• The ceiling on out-of-pocket payments requires a
  high level of documentation of paid bills
• Clients have difficulty maintaining records
• Some providers do not have the ability to collect
  and account for cash
• A problem in small and large institutions
• In large organizations, out-of-pocket payments
  are often not applied to the budget of the HIV
  program nor does the accounting system separately
  identify out-of-pocket revenue generated by the
  HIV program

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PLR Policies An Example of Enforcement Challenges
This is a partial list of providers who receive
Title III support from us. I'm sorry, but I
don't feel that I can send you all our referral
providers, as they may or may not know the funds
paying their fees are from Ryan White. It is up
to the patient to disclose to another provider,
and often, that means the provider may chose not
to provide services. This has happened on
numerous occasions, so please understand it would
not be in our patients' best interests to have
you contact all the providers we use. A Title
III Grantee
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PLR Participation in TPR

• Almost all CARE Act medical providers participate
  in Medicaid and other payers
• Some are locked out of Medicaid managed care
  plans who will not contract with them
• Some CARE Act providers funded for mental health
  and drug treatment services are not licensed and
  do not employ licensed supervisors or line staff
• Not eligible for participation in Medicaid
• May employ contractors that bill directly with no
  revenue returned to the program
• Some Medicaid programs have a moratorium on new
  provider numbers for certain provider categories
• Some CARE Act providers cannot afford
  credentialed personnel that would provide
  billable services

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PLR Participation in TPR Systems

• Managed care plans have considerable requirements
  that CARE Act providers may not meet
• 24/7 staffing, HIPAA compliance, staff
  credentialing, quality assurance, electronic
  claims submission, reporting, risk bearing
• Considerable infrastructure investment is
  commonly required for HIV providers to become
  ready for participation in managed care
• Case management and psychosocial support
  providers may not provide a billable service
• Do provide a billable services but are not
  sufficiently credentialed
• Some providers may not be aware that they provide
  a billable service
• Becoming a participating provider is likely to
  represent some costs often not covered by CARE
  Act capacity building funds

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PLR TPR Issues

• Many CARE Act providers are unaware of their per
  unit of service cost
• Tend to accept payments that are well below their
  actual costs
• Commonly have little bargaining power with
  insurers
• Personnel costs are reported to be rapidly rising
• Unionized organizations are bound by collective
  bargaining
• Grantee unit cost payments may be less than
  program costs
• Visits to HIV care providers tend to be
  relatively long and labor-intensive
• Volume is insufficient to generate increased
  marginal revenue
• Insolvency is increasing among HIV clinics
• In the past, parent institutions were willing to
  support administrative staff and related costs or
  absorb uncompensated costs
• Many of HIV programs report their institutional
  support has eroded rapidly as broader financial
  pressures increase
• An increasingly hostile environment is reported

25
PLR Billing Systems

• Many providers receiving CARE Act funds have
  inadequate billing systems
• In large systems, their billing systems do not
  separately account for HIV program revenues or
  expenses
• Some staff are not adequately trained,
  credentialed, or supervised
• Newer or small providers often try to build
  rather than buy billing staff capacity
• Evidence of coding insufficiency resulting in
  lower payments
• Do not research and resubmit rejected claims
• CARE Act providers are reluctant to require
  payment from self-pay patients
• No collections process in place even when
  patients have income
• Billing systems are not set up to do pay and
  chase
• Billing software, hardware, and
  training/re-training represent significant
  operating costs

26
PLR Billing Systems

• In some healthcare markets, CARE Act providers
  may potentially bill numerous payers
• Payers vary in their mechanisms for provider
  networks, covered benefits, and the amount that
  they will pay
• Prior authorization and standing order
  requirements must be addressed to ensure payment
• Payments may be slow, with claims commonly
  rejected at first submission
• This level of complexity is quickly outstripping
  the capacity of even relatively sophisticated
  providers
• HIV clinics tend to offer non-covered services
• Prevention, medication education, adherence
  counseling

27
Can veterans be required to receive services at a
VA medical center?

• In 2004, HAB clarified their policy about
  providing CARE Act services to HIV veterans who
  are also eligible for VA benefits
  http//hab.hrsa.gov/law/0401.htm
• CARE Act providers
• May not deny services, including medications to
  veterans who are otherwise eligible for the CARE
  Act
• Should inquire if an individual is a veteran and
  enrolled at the VA
• Should be knowledgeable about VA medical
  benefits, including medications
• Must coordinate health care benefits for veterans

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Why do some veterans receive care outside the VA?

• Concerns about quality in the VA system
• Even if enrolled for VA health care, a veteran
  does not have to use the VA as their exclusive
  health care provider
• The VA has limited resources and is funded each
  year by Congressional appropriations
• The VA encourages veterans to retain existing
  health insurance
• While veterans cannot be required to seek their
  care in the VA, CARE Act programs can provide a
  valuable service in making HIV veterans aware of
  VA services available procedures for getting VA
  care and helping them navigate care systems to
  secure HIV care

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What are the eligibility criteria for veterans to
receive services from the VA?

• Eligibility for most veterans health care
  veterans is based on active military service in
  the Army, Navy, Air Force, Marines, or Coast
  Guard (or Merchant Marines during World War II),
  and other criteria
• VA health care benefits are not just for those
  who served in combat or have a service-connected
  injury or medical condition
• Not all veterans are eligible for VA benefits
• In recent years, VA eligibility requirements have
  become increasingly strict

30
Can CARE Act grantees or subgrantees contract to
provide services to the VA?

• Yes, individual VA facilities or any of the 21
  regional Veterans Integrated Service Networks can
  contract with other agencies or groups to provide
  care to veterans
• Usually, this occurs when a specific service is
  not available in the VA system or when providing
  the service through a contract is more economical
  for the VA
• For clinical services, the VA must identify a
  need, develop a scope of work, and then obtain
  bids for the cost of providing the services

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EFFECTIVE ELIGIBILITY DETERMINATION
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Determination Pieces of the Puzzle

• Vast array of entitlement and discretionary
  programs that HIV clients might be eligible for
  today and tomorrow
• Things change!
• Eligibility criteria (the short list)
• Geographic residency, US citizenship, legal
  residency status, age, race (Native Americans),
  gender, previous financial contributions by
  client, employment, employer, preexisting medical
  condition, disability, employability, income,
  assets, HIV serostatus, CD4 count, annual or
  lifetime utilization of benefits, criminal
  convictions
• Knowing how to complete the paperwork, document
  claims, and making sure clients follow through

33
Determination Pieces of the Puzzle

• Disability claims are taking longer than ever to
  be processed
• Many State and federal entitlement programs have
  had layoffs or working with inexperienced staff
• SSA HIV policies are under review
• Legal services must be available to pursue claims
• Front-loaded intake and assessment at entry in
  care, without re-determination on a regular basis
  
• There is ineffective communication between care
  providers about eligibility triggers
• Loss of employment, inpatient admission, change
  in clinical condition

34
Challenges to Effective Determination

• The Entitlement, Discretionary, and Commercial
  System
• State and local discretion in the implementation
  of federal policy
• Lack of coordination of eligibility criteria and
  other federal, State, and local policies payer
  of last resort
• Whose client are you?
• Varying opinions about application of policies
  HRSA said
• Significant contraction of public benefits due to
  the economy, erosion of the tax base, competing
  demands, shifts in priorities
• Unwillingness of the commercial sector to take
  responsibility
• Loss of personnel in local and State government
  to operate the system
• Culture differences between HIV care systems and
  entitlement and discretionary systems

35
Challenges to Effective Determination

• AIDS Service Organizations and HIV Clinical
  Providers
• Tend not to maximize resources available in other
  systems
• Assume that case managers are handling it
• Assume somebody else will take care of
  determination rather than coordinating efforts
• Often take a passive approach to determination
  and do not make the system work for clients
  proactively
• Take the attitude dont ask, dont tell, giving
  the clients the impression that there is a free
  lunch
• Providers are often unaware that clients are
  already enrolled or eligible for care
• Do not coordinate applications for benefits
• Flood the system with completed forms to see
  what sticks

36
Challenges to Effective Determination

• AIDS Service Organizations and HIV Clinical
  Providers
• Front-load the intake and assessment at entry in
  care and do not effectively re-determine clients
  on a regular basis
• There is ineffective communication between care
  providers about eligibility triggers
• Loss of employment, inpatient admission, change
  in clinical condition
• Assume that clients disability claims should
  only be HIV-related
• Case managers are commonly used to conduct
  eligibility determination
• Training and retraining of case managers
  regarding eligibility determination is often
  limited
• There are competing demands for their time and
  turn-over is growing

37
Challenges to Effective Determination

• The Client or Patient
• Many providers assume that the client will be
  able to navigate the system
• Assume the ability to read and complete forms
• Other providers assume that the client cannot
  navigate the system when they can
• Determination processes that rely on clients are
  commonly doomed
• Paperwork is not the highest priority when you
  are trying to survive
• Clients are commonly not informed that providers
  rely on their ability to be paid for their work
• Concerns about discrimination and stigma may
  result in lack of complete disclosure

38
Determination Best Practices

• Collaboration between policymakers to establish
  policies and procedures that coordinate benefits
• Systematic assessment of the eligibility
  determination processes among HIV providers
• Centralize intake in EMAs or other jurisdictions
• Review organizational policies and procedures to
  determine what is actually being done in your
  program to determine clients
• Talk to your staff, review insurance status data,
  and review client records
• Develop continuous quality improvement (CQI) to
  improve determination
• Identify entitlement and discretionary programs
  for which there are barriers to enrollment
• Document the problem and establish ongoing
  processes for resolution

39
Determination Best Practices

• Establish processes to fast track applications
  and to train public and commercial claim
  assessment staff regarding HIV disease
• Routinely monitor changes in entitlement and
  discretionary programs that impact eligibility
  and adjust accordingly

• Fund and employ trained eligibility determination
  workers
• Broker roles and responsibilities among medical
  providers, case managers, eligibility
  determination workers, and legal aid providers to
  reduce duplication of effort and maximize
  enrollment
• Make sure that clients receive the maximum
  benefit to which they are legally entitled
• Communicate with clients that to continue to
  operate, your program must have revenue

40
On the horizon

• Deficit Reduction Act
• Proof of Medicaid beneficiaries claiming U.S.
  citizenship http//www.cms.hhs.gov/MedicaidEligib
  ility/05_ProofofCitizenship.asp
• Further Medicaid reforms
• Immigration legislation

41
On the horizon

• CARE Act Reauthorization
• Track using Thomas at http//thomas.loc.gov/

• Core service requirements
• 75 of Titles I, II, and III funds must be
  allocated to core medical services
• HHS shall waive this requirement if there is no
  ADAP wait list and core medical services are
  available to all HIV individuals
• Severity of need adjustment
• Moves to three-tiered Title I funding
• Eliminates double counting by Title I and Title
  II
• Moves to HIV name reporting as formula funding
  basis

42
What is the definition of primary medical care?

• Primary Medical Care (HR 5009 and S2339)
• Medication, prescription drugs, diagnostic tests,
  visits with physicians and medically credentialed
  health care providers, oral health, treatment for
  psychiatric conditions, and treatment for other
  health care conditions directly related to
  HIV/AIDS infection, and health insurance
  premiums, co-payments, and deductibles
• Does not include case management for non-medical
  services or short-term transitional housing

43
What is the definition of primary medical care?

• S2823
• Core Medical Services Outpatient and ambulatory
  health services, ADAP treatments, AIDS
  pharmaceutical assistance, oral health care,
  early intervention services, health insurance
  premium and cost sharing assistance for
  low-income individuals, home health care, hospice
  services, home and community-based health
  services (except homemaker services), mental
  health services, substance abuse outpatient care,
  medical case management (including treatment
  adherence services)
• Support Services A grantee, subject to the
  approval of the HHS Secretary, may provide
  support services
• Such as respite care for individuals with
  HIV/AIDS, outreach services, medical
  transportation, nutritional counseling,
  linguistic services, and referral for health care
  and support services for individuals with
  HIV/AIDS
• Needed to achieve medical outcomes which are
  related to the medical outcomes for HIV
  individuals

44
Florida Medicaid Reform

• Authorized by FL Legislature in May 2005
• Waiver was submitted to CMS in October 2005
• Waiver was approved by CMS in 2005
• Approved by the FL Legislature in December 2005
• Roll out will begin in Duval and Broward
• Enrollment throughout FL by July 2008

45
What Florida Medicaid Reform Will Not Do

• Reform will NOT change who receives Medicaid
• Eligibility does not change
• Reform will NOT cut the Medicaid budget
• The budget will continue to grow each year
• Reform is NOT correlated with Medicare Part D
• Florida will NOT limit medically necessary
  services for pregnant women
• Florida has NOT asked to waive Early and Periodic
  Screening Diagnosis and Treatment (EPSDT) for
  Children
• Children will be able to access all medically
  necessary services
• Florida will NOT increase beneficiary cost
  sharing requirements

46
What Florida Medicaid Reform Will Do

• Increase access to appropriate care
• Benefits that better meet recipients needs
• Access to services not traditionally covered by
  Medicaid
• An opportunity to provide choice and control to
  recipients in regard to health care decisions
• Ability to earn credit to pay for non-covered
  services
• Bridge to private insurance

47
Key Elements of Medicaid Reform

• New Options/Choice
• Customized Plans
• Opt-Out
• Enhanced Benefits
• Financing
• Premium Based
• Risk-Adjusted Premium
• Comprehensive and Catastrophic Component
• Delivery System
• Coordinated Systems of Care (PSN and HMOs)
• HMOs are capitated
• Provider Service Networks (PSNs) are FFS for up
  to three years, then capitated

48
What will change with Medicaid reform?

• A roll-out of mandatory enrollment for most
  assistance categories (e.g. TANF, SSI), with full
  implementation slated for July 2008
• Comprehensive choice counseling by an independent
  enrollment broker
• Counseling will be provided in person, by phone,
  in writing, or through the media, with
  Internet-based enrollment offered
• Detailed information will be provided to
  enrollees
• Eligible enrollees must chose a plan
• New enrollees will receive only emergency
  services until they enroll or are auto-assigned
  to a plan
• Enrollment broker must employ a culturally
  diverse counseling staff
• Florida State University will offer a Choice
  Counselor Certificate and develop outreach
  materials
• Education needs will dramatically change
• Recipients will need to understand differences in
  the benefit packages plans offer
• Information on opting out of a Medicaid plan will
  be provided

49
Customized Benefit Packages

• Plans may vary amount, duration, and scope of
  certain services for non-pregnant adults
• Certain services must be provided at or above
  current coverage levels
• Other services must be provided to meet
  sufficiency standards for the population
• Remaining services must be offered, but amount,
  scope and duration are flexible
• Reform plans can enhance any service above
  current levels
• Reform plans can add services not currently
  covered

50
Customized Benefit Packages Required at Least to
Current Limits

• Physician and physician extender services
• Hospital inpatient care
• Emergency care
• EPSDT and other services to children
• Maternity care and other services to pregnant
  women
• Transplant services

• Medical/drug therapies (chemo, dialysis)
• Family planning
• Outpatient surgery
• Laboratory and radiology
• Transportation (emergent and non-emergent)
• Outpatient mental health services

51
Additional Required or New Benefits

• Required for sufficiency
• Hospital outpatient services
• Durable medical equipment
• Home health care
• Prescription drugs
• Required to be offered, but amount, scope and
  duration are flexible
• Chiropractic care
• Podiatry
• Outpatient therapy
• New or expanded benefits
• Over-the-counter drug benefit from 10-25 per
  household, per month
• Adult preventative dental, including x-rays,
  cleanings, and fillings
• Newborn circumcisions
• Acupuncture/medicinal massage
• Additional adult vision lt 125 per year for
  upgrades such as scratch resistant lenses
• Additional hearing lt 500 per year for upgraded
  digital, canal hearing aid
• Home delivered meals for a period of time after
  surgery, providing nutrition essential for proper
  recovery for elderly and disabled

52
Medicaid Reform Plans And Networks Broward
Duval
53
How will impact of Medicaid reform on HIV
enrollees?

• HIV enrollees must chose a plan
• HIV enrollees identified in Medicaid claims
  files may be auto-assigned to a plan agreeing to
  provide HIV enhanced benefits or be assigned to a
  general plan and have to ask to be move to a plan
  with the enhanced HIV benefits ? stay tuned
• All plans can access an enhanced capitated
  monthly payment that adjusts for the higher cost
  of HIV
• Protease inhibitors and other HIV medications are
  included in the HIV/AIDS capitation rates
• Plans will be required to meet HIV access
  standards which are being developed now
• Home and community-based waiver services will be
  carved out of the covered benefits package
• PAC Waiver clients can continue to receive their
  services through that program
• Plans must provide case management directly or by
  contract
• The HIV disease management program will be phased
  out in counties as the Medicaid reform roll-out
  is implemented

54
Proposed Per Member Per Month Capitated AIDS,
HIV, TANF and SSI Rates Duval and Broward
Rate for TANF female enrollees
55
Stay Tuned for New Medicaid Reform Developments

• http//ahca.myflorida.com/Medicaid/medicaid_reform
  /

56
Capitated And Fee for Service Contracting
57
Roles In Commercial Insurance and Managed Care
Systems For CARE Act Grantees And Providers

• Contracting as a network provider
• Forming alliances with plans to provide
  grant-funded services through linkage agreements
• Advisors regarding program planning, development,
  clinical standards and service delivery
• Becoming a managed care plan
• Advocacy and monitoring

58
Why participate?

• Enhance the quality, accessibility, coordination,
  and continuity of care for HIV enrollees
• Ensure your agencys ability to access HIV
  enrolled in managed care plans so your agency can
  offer them grant-funded prevention and
  psychosocial services
• Improve your agencys likelihood of financial
  survival
• Diversify your agencys client and income base
• Influence governance and policy making process
  within managed care plans
• Adopt sound business practices used by managed
  care plans to improve your agencys products and
  more efficiently use scarce resources

59
Why managed care plans may be disinterested in
your agencies participation in their network

• Adverse selection. Attracting members who are
  sicker than the general population.
• This results in higher than budgeted expenses for
  the plan
• MCOs may avoid enrolling individuals who are
  sicker than the average patient
• Some MCOs may avoid enrolling HIV individuals
  because of their relatively high treatment cost

60
Managed Care Elements

• Combines financing and delivery systems
• Patients receive a defined benefits package
• Patients usually select or are assigned a
  primary care provider (PCP)
• PCPs act as a gatekeeper who determines access
  to specialists, hospital care, and other services
• Clearly defines patient populations, modify their
  care seeking behavior, and predict their care use
  and costs
• Identifies and minimizes financial risk while
  maximizing profitability
• Identifies high risk and high cost patients
• Organizes systems of care that achieve these
  goals
• Payment is typically paid on a prospective,
  capitated basis, but FFS payments may be made
  for some services

61
MCO Functions

• MARKETING
• MEMBERSHIP ACCOUNTING
• Group billing, contracts, enrollment, and PCP
  assignment
• NETWORK OPERATIONS
• Provider credentialing and contracts
• MEMBERSHIP SERVICES
• Education and grievances
• CLAIMS ADMINISTRATION
• MIS
• FINANCE
• Budget projections and capitation rates
• UTILIZATION MANAGEMENT AND QUALITY ASSURANCE

62
HMO And Other Managed Care Models

• Staff Physicians are HMO employees
• Group Physicians are members of a single or
  multi-specialty group practice that contracts
  with the HMO
• IPA Either the physician contracts directly with
  the HMO or through a physician corporation
• Network HMO contracts with group practices,
  IPA-physician corporations, and/or with
  individual physicians
• Point of Service (POS) HMO offers members the
  option to receive services from non-MCO providers
  at a reduced rate of coverage
• Preferred Provider Organization (PPO) A system
  that contracts with providers at discounted fees
  members may seek care from non-participating
  providers, but at higher co-pays or deductibles
• Integrated Service Network (ISN) A collaboration
  of either PCP (horizontal) or primary, specialty,
  and inpatient providers (vertical) for managed
  care
• Physician Hospital Organization (PHO) legal
  entity between hospital and physicians to
  contract with MCOs

63
What is capitation?

• A reimbursement method for health and associated
  services in which a provider is paid a fixed
  amount
• Payment is usually monthly for each member served
• Payments occurs without regard to the actual
  number or services provided to the member
• Capitation is a
• Means for payment for expected services
• Budgeting tool
• Management tool
• Cost control tool

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Monthly Capitation
Utilization x Cost 12 months x 1,000
members

PMPM
Utilization number of units of service for each
benefit for 1,000 members
Cost average cost per unit of service
PMPM per member per month capitation payment
65
Assumptions Underlying Capitation Rate Setting

• Covered and excluded services are clearly defined
• The average utilization rate per service is known
  or can be accurately projected
• If the average utilization rate varies by
  population group, their rates are known or can be
  projected
• The cost per service is known and is unlikely to
  vary during the contract period
• Administrative costs are accurately defined
  (i.e., there are no hidden costs) and adjustment
  can made in the PMPM for those costs
• Can additional revenue (i.e., grant income) be
  used to supplement the PMPM
• Discounts may be taken for efficiency

66
Utilization Management

• Prior or pre-authorization (e.g., expensive or
  commonly over-used services)
• Medical necessity, contracted facility,
  cost-effectiveness
• Referrals
• Part of gate-keeper function of PCP
• Concurrent reviews
• Is the ongoing service too long and can other
  services be substituted?
• Formularies
• Open versus closed formularies, generics,
  cheapest delivery system
• Claims review
• Appropriateness review
• Provider selection and profiling

67
Risk Protection Strategies

• Stop Loss / Reinsurance
• Establishes an upper limit on annual health care
  costs for an individual member
• Aggregate stop loss sets an upper limit for
  members
• Managed care plans usually purchase reinsurance
• Providers can negotiate stop loss with the plan
• Risk Corridors
• Establishes a ceiling and floor of risk
• Loss greater than the predetermined amount is
  reimbursed (e.g., 10 over costs)
• Profit greater than the predetermined ceiling is
  returned to the plan

68
Organizing HIV Services in Managed Care Settings

• Training and experience of clinical staff and
  their willingness to treat HIV patients
• Ability to rapidly disseminate new therapeutic
  approaches and provide on-going training
• Contractual relationships with HIV specialists
  and social support programs
• Up-to-date quality assurance programs
• Attitudes of other patients treated in same
  settings and communities in which services are
  provided
• Adequacy of capitation rate setting system to
  cover current and anticipate future HIV costs
• Confidentiality, disclosure, and privacy
• Case finding and outreach
• If your organization is negotiating with plans,
  make sure that they have considered the unique
  clinical needs of your patients!

69
Network Standards

• Availability of HIV-experienced PCPs and
  specialists
• Standing referrals to specialists
• HIV-experienced clinician should be gate-keeper
• Role of HIV-experienced clinician in developing
  and implementing care plan
• Use of multi-disciplinary teams
• Identifying HIV-experienced clinician to be
  responsible for care coordination
• Continuity standards for referrals
• Adequacy of network capacity to assure delivery
  of covered benefits (e.g., panel sizes)
• Accessibility standards
• Travel time, appointment scheduling time, visit
  wait time, 24 hour coverage by a real person,
  geographic coverage, culturally acceptable
  services and providers
• Fiscal solvency

70
Network Member Selection Criteria Choosing Your
Partners

• Established provider network
• Geographic coverage
• Sufficient capacity and accessible services
• Acceptable marketing, enrollment, grievance, and
  disenrollment procedures
• Established quality assurance program
• Fiscal solvency
• Established administrative and governance
  structure
• Meets State licensure criteria

71
How can we limit risk in capitation contracting?

• Request risk adjusters in payment (e.g., active
  IDUs)
• Define precise boundaries between clinic services
  and other physicians care, to avoid dumping
• Use internal distribution structures which align
  individual and group incentives

• Request demographic risk adjusters in payment
• Obtain historical usage data on the population to
  be served or from a comparison group
• Gain experience with small-scale contracts
• Ensure that adequate termination options exist
• Make sure health plan is a reliable business
  partner

72

How can we find out which managed care plans
operate in our HIV programs service area?

• COMMERICAL HMOS
• Dually regulated by AHCA and the Department of
  Financial Services
• AHCA monitors quality of care-related issues
• DFS monitors financial and contractual issues
• To become a commercially licensed HMO, an
  organization must receive a health care provider
  certificate from AHCA and a certificate of
  authority from DFS
• A list of plans by county is available at
  http//www.floir.com/mc/is_mc_index.htm

• MEDICAID PLANS
• Regulated by the AHCA Bureau of Managed Health
  Care
• A list of plans is available at
  http//www.fdhc.state.fl.us/MCHQ/Managed_Health_Ca
  re/MHMO/index.shtml

73
Assessing Your Programs Costs
74
Several Approaches Are Used to Estimate Unit Cost

• Grant-funded costs Total budgeted amount /
  the number of estimated units to be provided
• Negotiated payment rates based on documented
  direct and indirect costs
• Rates based on grantees rate setting
• Relative value units (RVUs)
• RVUs measure the intensity of services based on
  the level of skill involved, the duration of the
  service, and the facility and overhead support
  required
• For medical services, we use RVUs from the
  Resource Based Relative Value System (RBRVS)

75
TACT

• HAB Technical Assistance Costing Tool (TACT) is
  designed for clinics and individual medical
  providers who want to identify the costs of
  delivering health care services to HIV patients
• TACT reports provide cost analyses for internal
  clinic financial management for third-party
  reimbursement
• A MS Excel-based software tool with a data-entry
  sheet and two printable reports
• The design allows users to customize the type of
  service categories, define the patient
  population, and enter financial and utilization
  data on the Input worksheet tab
• TACT shows costs as per member per month and per
  unit of service for ambulatory, inpatient, and
  ancillary services
• Find TACT at
• http//www.hrsa.gov/TACT/manual/TactManualTOC.html

76
TACT

• TACT calculates and reports costs for each type
  of medical care that your clinic provides
• The calculations are done two ways
• FFS cost (the estimated cost of one unit of care,
  for example an office visit)
• Per-member-per-month cost (the estimated cost of
  providing all care to one individual during an
  average month)
• To use TACT, you need to determine
• Annual member months, which is the number of
  individuals to whom you provide care times twelve
• Annual member utilization of service for each
  care type provided, or how much service is
  provided
• Total annual cost of providing each care type

77
Relative Value Units (RVUs) Approach

• RVUs measure the intensity of services based on
  the level of skill involved, the duration of the
  service, and the facility and overhead support
  required
• For medical services, RVUs are derived from the
  Resource Based Relative Value System (RBRVS)
• An RVU scale assigns numerical values to the
  intensity of procedures
• Example a basic office visit for an existing
  patient (CPT code 99211) has an RVU of .56,
  which indicates a low intensity of the procedure.
  A surgical procedure such as a complicated
  nephrectomy (CPT code 50225) has an RVU of 31.79,
  indicating the high intensity of the service.
  This suggests that the nephrectomy requires
  almost 57 times more effort in terms of time,
  skill, and resources than a basic office visit.

78
Components Of RVUs

• There are three components of medical RVUs
• Work - measures the provider skill and effort
  required to complete the service Work RVU for a
  99213 .67
• Overhead - measures the overhead resources
  required to complete the service Overhead RVU
  for a 99213 .69
• Malpractice - measures the malpractice risk
  associated with the particular procedure.
  Malpractice RVU for a 99213 .03
• Total RVU for a 99213 .67.69.03 1.39

79
Evaluating Support Services

• RSM McGlandrey has expanded the use of RVUs to
  HIV enabling/supportive services
• Example case management, health education,
  interpretation, service coordination,
  transportation, and volunteer services
• This approach can help your program to evaluate a
  range of issues associated with the provision of
  enabling services, including
• What enabling services are being provided?
• What resources are required?
• What can we do with this information?

80
Potential Applications

• Utilize Fee Schedule to Negotiate/Evaluate
  Reimbursement
• Determine if FFS rates offered by payors cover
  the costs of providing services
• Agencies can either negotiate individually using
  their own fee schedule or using a group of
  agencies global fee schedule
• The global fee schedule developed reflects the
  costs of providing services at your agency
• Individual fee schedules reflect your program
  costs of providing services
• Compare the amount of funds awarded by CARE Act
  grantees with the cost of providing services
• Compare capitation rates proposed by payers with
  the cost of providing care

81
Potential Applications

• Monitor Patterns of Care
• You can modify the tracking forms to capture
  patient information and then use as a basis to
  monitor enabling services provided to patients
• This would allow you to track the care provided
  to patients and ensure that is consistent with
  their condition/diagnosis
• Use Taxonomy to Track Enabling Services on an
  Ongoing Basis
• You can input the taxonomy of services into your
  MIS to track services provided here forward
• This approach allows you to monitor utilization,
  consider carving-out grant-funded
  programs/services, and seeking separate funding
  sources to cover the costs of providing services

82
Potential Applications

• Use RVUs to Track Provider Productivity
• RVUs, rather than patient visits, are rapidly
  becoming the standard for measuring provider
  productivity
• This is especially important for HIV/AIDS
  providers, where the patients are by definition
  of high and varying medical complexity
• RVUs for enabling services can be used to measure
  the productivity of non-physician staff

83
Step 1 Develop standard coding methodology and
Daily Service Tracking Form

• McGlandrey staff with your agency to identify and
  define the enabling and medical services
  performed by providers
• Enabling services were defined at the unit level,
  with standard durations and provider types for
  all SHN services
• A standard coding system was assigned to each
  enabling service
• A Daily Service Tracking Form is developed for
  each provider type, listing the codes and
  duration for the services performed by that
  specific provider
• Each form included blank columns for tracking the
  frequencies of service performed and patient ID
  number, as well as blank lines for provider name
  and date

84
Step 2 Perform one-month time study of services
performed

• For a four-week period, front-line staff track
  all enabling services performed using the Daily
  Service Tracking Form
• It is usually necessary to use the form because
  MIS do not capture frequency of services
  performed
• The one-month time study is the minimum length of
  time necessary to capture a representative sample
  of services
• The CPT codes provided during the time study
  period are taken from your MIS and combined with
  the enabling services provided to form the basis
  of the Unit Cost per Service Analysis

85
Step 3 Developing RVUs for Enabling Services

• Since enabling services are not assigned a CPT
  code, none of the RVU scales, including RBRVS,
  have corresponding RVUs
• Thus, McGlandrey develops RVUs for the unique
  enabling services provided by your agency

86
Step 4 Calculating a Cost Factor for each RVU
and a Cost per Service

• Results of the time study are used to calculate a
  cost per RVU
• Includes both the enabling services tracked using
  the Daily Service Tracking Form and services data
  your MIS
• McGlandrey calculates the cost per RVU by
• Multiplying each service codes frequency by its
  RVU to calculate a weighting factor
• Adding the weighting factors for all services to
  arrive at total RVUs
• Dividing the total organizational costs by the
  total number of RVUs to derive a cost per RVU
• Multiplying cost per RVU by each services RVU to
  arrive at a cost per service

87
Sample Findings - Service Activity

• On average, about 2.56 enabling services were
  provided per patient visit
• The distribution of total medical and enabling
  services provided to patients during the time
  study period is as follows
• Number of Services of patients receiving
  services
• 1-2 51
• 3-5 27
• 6-10 12
• 11-74 9
• The maximum number of enabling RVUs provided to
  any one patient during the time period was 35.23
• The cost of providing these enabling services to
  this patient was approximately 1,685
• On average, providers performed about 4.2
  enabling services per day

88
Findings - Service Costs

• A cost schedule is developed by calculating the
  average cost per service
• Costs for the most frequently performed services
  are
• Service Description Cost
• 99215 Office/Outpatient visit, est. 129.17
• CT002 Case Report for clinical trial 24.40
• RN001 Nursing triage - telephone 17.22
• CM023 Individual Supervision 46.88
• CM008 Follow-up on entitlement 17.22
• 90782 Injection (SC)/(IM) 5.26
• SS002 Entry to social service organization
  17.70
• CM020 Pharmacy refills - nurse 13.87
• 99233 Subsequent Hospital Care 103.33
• CM010 Transportation to Offsite Provider 14.35

89
Effective Marketing to Managed Care and
Commercial Insurance Plans
90
Developing Your Marketing Plan

• Understand the plans obligation to the Medicaid
  Program, employers, or others
• Determine their corporate objectives
• Are they looking for cost-effective providers?
• Do they need providers in your geographic area?
• Do they need HIV-experienced providers?
• What has been their attitude toward other
  community-based providers?
• Do they currently serve HIV/AIDS patients?
• What is their track record?

91
Developing Your Marketing Plan

• What is your product?
• How many plan members could benefit from your
  product?
• Will your product attract new members to the
  plan?
• How much does your product cost?
• Will the plan have to pay for your product (e.g.,
  grant-funded service)?
• Are you willing to share some financial risk with
  the plan?
• What distinguishes your product from that of
  another provider?
• Will your product enhance the plans network?
• Will your product help meet Medicaids benefits,
  network, access, or quality assurance standards?

92
Developing Your Strategy

• Form a network of HIV care providers to present a
  united front
• Minimize unnecessary competition
• Identify effective individuals to negotiate with
  plans
• Present a positive corporate image
• Minimize negative perceptions of managed care
  plans
• The costume makes the man
• Prepare marketing materials that present a
  positive business image

93
What you are selling

• We have experience in
• Delivering clinical services that reflect the
  state-of-the art of HIV care
• Delivering clinical and psychosocial services to
  hard-to- reach populations
• Managing behavior to achieve positive clinical
  and psychosocial outcomes
• Avoiding or reducing psychosocial crises that
  reduce adherence to clinical regimens
• Delivering culturally sensitive and appropriate
  services
• Working in an integrated network of clinical and
  wraparound services
• Delivering cost-effective services through low
  overhead

94
Example of Effective Marketing Materials

• Prototype materials developed by three integrated
  HIV care networks
• Central Pennsylvania
• Michigan
• Staten Island/Lower Brooklyn New York
• http//www.gwhealthpolicy.org/cihcn_publications.h
  tml

95
Effective Management Strategies Improving Your
Bottom Line
96
Overview

• Essential functions to expedite payment
• Pre-Visit Activities
• Patient Visit Activities
• Post-Visit Activities
• Management Activities

97
Pre-Visit Activities Scheduling Staff

• Allow sufficient time for each visit
• Determine reason(s) for visit (e.g, general
  checkup, physical examination, referral,
  follow-up)
• Remember that new patients consume more
  registration, financial counseling, health
  records and provider staff time
• Collect patient demographic and insurance
  information
• At minimum, patient name, address, and telephone
  number (if any), insurers name (including any
  secondary payer(s) and patients insurance
  identification number(s)
• Verify insurance coverage
• Ensure that coverage extends through visit date
• Determine and secure required pre-authorizations

98
Pre-Visit Activities Scheduling Staff

• Determine need for financial counseling
• Inform patient regarding the basic visit fee and
  any outstanding balance from prior visit(s)
• Instruct uninsured patients to bring
  documentation needed to apply for sliding fee
  discount
• Educate patient regarding your payment policy
• Example payment, including applicable
  deductible or co-payment, is expected on date of
  service
• Establish a payment schedule and monitor patient
  adherence
• Schedule time with financial counselor, as
  necessary

99
Pre-Visit Activities Scheduling Staff

• Develop, maintain, and always consult log of
  chronic no show patients before assigning
  appointment times
• Inform negligent patients about their history,
  the preparation required for each visit and,
  therefore, the importance of either keeping or
  calling to cancel appointments
• Double book chronic no shows and/or slot them
  at the end of the day
• Confirm patient appointments, if possible, prior
  to visit (e.g., day before)
• Re-schedule cancelled appointment slots
  immediately

100
Patient Visit Activities

• Registration staff should
• Instruct patients to sign-in at registration desk
  upon arrival
• Pull health record, with attached pre-populated
  encounter form or create record for new patient
• Number and, as appropriate, complete
  pre-populated encounter form
• Collect basic visit fee, co-payment or deductible
  give patient a receipt for payment
• Transport completed encounter form and record to
  assigned exam room

101
Patient Visit Activities Registration Staf