Healthcare Updatechallenges and opportunities

Taino Consultants Inc.

Dr. Jose I. Delgado

Main Topics

• Affordable Care Act – Exchanges• Insurance Products and Patient Responsibility• Action Items for CY 2013

Exchanges• What are the exchanges• Products• What does it means to you

What are the Exchanges?

• Online shopping marketplace (i.e. Amazon)

• Type of Exchanges– State– Federal– Hybrid– Commercial

Products

• Plans defined by Insurance Companies– Healthcare Professionals and Organizations may not be participating in all Plans/Products– Plans have controls on who they want to participate– Closed Networks

• Patients Shopping based on price– Lower Monthly = higher out of pocket– Lower monthly = restricitve Networks

Companies and average changes (FL)

Local Plans

Individual Family

Monthly Cost $500 - $700 $1,200 - $1,600

Co-pay Primary $50 - $100 $50 - $100

Co-pay Specialist $50 - $100 $50 - $100

Deductible $6,000 $8,000

Higher co-pays and deductibles means• Patients increased financial

responsibility– Most of the money will be collected

from the patient– More cash, checks, credit cards

transaction in the office– Best and most efficient method to

collect is at the office– More questions from patients as they

may not understand their costs and coverage

– Potential higher costs for billing Companies

Risks of cash

• Re-education of patients• Difficulty on receiving

payment from individuals• Theft• Costs

Other Issues to consider

• In/out of Network– Smaller Network easier to manage

• Allowables – Fee schedule– Contract fees (beware of “based on …….”)

• Cost of doing business– Overhead rate?– Cost of your services?

• Cost of sending invoice?

Risk and Reimbursement

• Affordable Care Act provides consumers with 90 days to go without paying their premiums and not lose coverage– Insurers don’t have to process claims– Providers must continue to offer services without

payment

• Lower Reimbursement from Exchange Products– For example: BC/BS of Illinois premiums are 20-30%

lower – Increased volume doesn’t equal increase reimbursement

What does it means to you

• Business Operations changes– Cash fail safe operations – Cost increases?

• Relationships (Peers, Networks)– Return on investment?

• Marketing– Pick you clients/take control– Be Proactive

It is not business as usual!

ACA Compliance more than Insurances

• OIG compliance plan required– Conduct audit– Develop Policies and Procedures

• OIG Sanction list

http://oig.hhs.gov/exclusions/

– Train staff– Document actions

Meaningful Use beyond EHR

• Audits– Random and conducted by CPA firm– Documentation needed– Failure one item requires return of incentive

• Interaction with other laws– False Claims Act (30 day window to return money

from discovery)

• Action Items– Risk Analysis– Documentation

HIPAA Security – Omnibus Rule

• Business Associate Contracts– Obtain assurances

• Risk Analysis• Risk Management (policies and procedures)• Breach Response & Breach Notification• Training

Summary

• Significant changes that will affect all aspect s of the Healthcare Business

• Healthcare and Professionals must take control to survive– Consider key aspects:

• Return on Investment• Income Generating Activities• Marketing and selecting right patient mix• Risk and required actions

Dr. Jose I Delgado904-794-7830

DrDelgado@Tainoconsultants.com

www.tainoconsultants.com