Our New World Medicaid MCO/MLTC’s and the world of HMO’s

A Billers Perspective

1

HMM, CPAs LLC – Healthcare 360 Seminar 12/1/2016

What we want to accomplish today:

• A better understanding of the day to day challenges that the MLTC Transition has created

• Suggest some practical solutions

2

FFS Versus HMO FFS 1. No Auth needed 2. Batch claims via electronic

submission 3. 277 file verification of file

acceptance 4. Claims denied or suspended

according to exact reason codes 5. Call in to CSC for check amount

(predict cash flow) 6. Clarity on status of all claims ,no

need to ever call for status 7. Check received on specific cycle, in

one batch 8. Software automatic posting of

batch remit

HMO 1. Need Authorization 2. Claims need to be sent to multiple payors,

some via paper claims. No consistent method

3. No consistent method to verify claims acceptance

4. Claims deny for all sorts of unexplainable reasons

5. No method to predict how much is paying until check/eft received

6. Denials are not consistent, make no sense and lack of clarity. Need to constantly call for status

7. Claims pay all different times even from the same payor who received one file with a few claims

8. No automatic posting. The remits are mostly not batch claims payment 3

More Choas with the MLTC Transition • Language of the contracts are not consistent from one payor to the next • Some counties have more MLTC operating than in other counties, leaving

some facilities with as many as 20 HMO’s to work with (huge workload to bill multiple different insurances) and some facilities with only 1-2 HMO’s (mostly upstate)

• Nami’s are not dealt with consistently with all Plans. Complete chaos • Retros are not consistent with all Plans • Timely Filing restrictions deadline are not consistent (and very hard to

adjust to after Medicaid which was 2 years) • Rates are not posted timely, and some Plans don’t update timely resulting

in plans paying the wrong rates. • Pay cycles are not consistent leaving cash flow in a crunch with no method

of predicting incoming cash • Changes of ownership (CHOW’s) are a complete mess with the HMO’s.

Auth’s are entered under old NPI, billing under the new NPI etc… 4

More Choas with the MLTC Transition

5

What we see in other States:

• Few (2-4) plans per county only • Same contract between Plans and facility for all payors • Online portals to update claims, receive confirmation and batch pay • Coding consistent and denials are very specific reasons • Some states don’t require authorization • Mandated pay cycle (14-20 days) • Nami setup consistent for all Plans • Uploading rates and retro’s has an efficient system and method

6

2 Areas of Focus

1. Authorization process

2. Claims Processing

7

Authorization Process •New Admissions •New admissions to the Plan (current patient recently approved Medicaid)

•Re-authorization after 6 months •Authorization when the patient changes Plans

8

Challenges with Authorization

• Volume of patients that need authorization increasing as your long term population transfers over to HMO’s

• Plans not returning phone calls timely • Plans denying auth stating patient is not appropriate for nursing

home care • Plans approving for specific days for coinsurance days, and/or inhouse

days based on the patient going on/off Medicare, but those days could be wrong. Getting corrected auth’s are very challenging

• Auth’s not being received for higher rate for specialty beds

9

Claims Processing - Challenges • Claims need to be sent to multiple different payors, via different

methods • No electronic method of verifying that the Plans received all claims

and are processing them • Coding not uniform between insurance companies

10

Basic Revenue Codes MLTC Skilled HMO Commercial

R &B 100 191 120 Vent 169 192 Aids 160 193

Bedhold 185 194 TLOA 183

We have seen the following inconsistencies: MLTC Skilled Hmo/Commercial

R &B 100, 101, 120 or 191x 110, 120, 190, 121, 128

Claims Processing - Challenges • Inappropriate denials:

• Many are not understandable • Rate code wrong or doesn’t match auth. (coins days/Per diem days) • Patient not authorized • Patient not in the plan • Denied for Medicare EOB (DOH clarified it is only needed on first claim) • LIST IS ENDLESS

• Claims adjustment – Many payors don’t know how to handle adjustments creating many delays and unanswered reasons why claims are not paying

• Claims approved, but awaiting pay cycle. No enforcement from DOH how fast Plans need to pay claims that are approved for payment

11

What Facilities can do to improve cashflow

Facilities need to delegate more hours to the authorization, and re-authorization process

12

Tracking sample Nursing Home Name

NAME # OF

DAYS PER BENEFIT

BENEFIT PERIOD INSURANCE

LEVE

L AUTHORIZATION TOTAL DAYS GIVEN

AUTH. Number DATE QUALIFIERS INFO.

SCHEDULE EXPECTED DATE OF

DISCHARGE

QUALIFIERS / SKILL SERVICE CASE MANAGER FAX # TEL. # ADM.

DATE LAST DAY OF COVERAGE

START DATE END DATE REHAB

NOTES FAX

SENT NEXT

UPDATE

WELLCARE

Name Med Necess 9/1/16 N/A Wellcare 2 09/01/16 11/04/16 64 12690292 Yes 10/28/16 11/4/16 ? PT/OT

Skilled Nursing 877-844-8538

Name 100 Days 10/11/16 Wellcare 2 10/11/16 11/02/16 120451376 Yes 10/25/16 11/2/16 ? PT/OT

Skilled Nursing 877-844-8538

CDPHP

Name Med Necess 2/5/16 n/a CDPHP MA 1 04/01/16 11/04/16 217 160910345 Yes 10/28/16 11/4/16 LongTerm PT/OT/Nursing

Katie Speck 518-3402 518-641-3460

Name Med Necess 4/13/16 N/A CDPHP MA 1 04/22/16 11/01/16 193 161040286 Yes 10/25/16 11/1/16 Wounds

Skilled Nursing 518-641-5206 518-641-3376

Name Med Necess 10/4/2016 N/A CDPHP 2 10/4/2016 11/2/2016 29 162780425 Yes 10/25/2016 11/2/2016 ? Wounds,IV ABX, Dialysis, Therapy Skilled Nursing 518-641-5206 518-641-3376

Name Med Necess 9/8/16 N/A CDPHP MA 2 09/08/16 11/03/16 56 162510312 Yes 10/27/16 11/3/16 ?

PT/OT Skilled Nursing 518-641-5206 518-641-3376

FIDELIS

Name Med Necess 4/27/16 6/22/16 Fidelis MA 1 06/22/16 11/01/16 132 161181607 Yes 10/25/2016 11/1/16 LongTerm OT/Nursing

Skilled Nursing 716-803-8307 888-343-3547

Name Longterm 8/12/2015 MLTC Fidelis MLTC 1 Cust 6/1/2016 11/30/2016 182 161943138 No 7/28/2016 12/1/2016 LongTerm Nursing 718-906-0883 516-344-6093

Name Med Necess 9/14/2016 N/A Fidelis MA 1 10/5/2016 11/3/2016 29 1625830857 Yes 10/26/2016 11/3/2016 ? PT/OT Skilled Nursing 716-803-8307

Name Med Necess 9/14/2016 N?A Fidelis MA 2 9/14/2016 11/3/2016 50 162581429 Yes 10/27/2016 11/3/2016 ? Pt/Ot Skilled Nursing 716-803-8307

Name 100 Days 9/14/2016 Fidelis MCR 2 9/14/2016 11/2/2016 49 162580502 Yes 10/26/2016 11/2/2016 ? PT/OT Skilled Nursing 716-803-8307

Name 100 Days 9/29/2016 Fidelis MCR 2 9/29/2016 10/27/2016 28 162720570 Yes 10/6/2016 10/28/2016 d/c hos

10/28/16 PT/OT Skilled NUrsing 716-803-8307

BCBS

Name 60 Days 10/25/2016 BCBS 2 10/25/2016 10/31/2016 908-9394 Yes 10/25/2016 10/31/2016 ? PT/OT Skilled Nursing 800-537-7371

OTHER 13

What Facilities can do to improve cashflow • Claims Processing

• HMO billers need to be set up to have ability to:

• Call for status on every claim 30 days after submission • Resolve every claim not in pay status by requesting claims to be reprocessed,

and/or responding to the reasons that the claims are denied or pended • HMO Biller must have a way to Track and follow up on all Denials/pending claims

with notes and details • Send in appeals and complaints to DOH as appropriate • The necessity of 30 days even though 60% of the calls would have paid anyway.

Need to “catch the problematic ones” in time to correct before timely filing deadlines

Facilities need to delegate more hours for HMO Billers to follow up on every outstanding claim every 30 days and address every issue on every claim

14

Sample tracker of claims – Database with queries

15

What CFO’s/Controller can do • Need to review aging constantly to analyze the issues:

• Is there a consistent issue with claims denials which might indicate the HMO biller is not on their game

• DOH will not listen to your complaint if your staff is not on their game • Is there a consistent issue with claim denials which might indicate the

authorization have issues • When reviewing the aging, you need to determine which payors are becoming

problematic – need to be familiar with the patterns of each payor • Facilities should add additional staff, more experienced staff or

outsource billing to professionals for maximum collections. Facilities cannot afford to leave money on the table

• Due to tight timely filing deadlines, (FFS was 2 years) and tight claims corrections and appeal deadlines, there is no room for error when a biller resigns, goes on vacations…

• One biller to do be experienced and fluent in all payors is very challenging

16

Auth delays directly effect claims • When auth is obtained late, and billing goes out timely, claims will be

denied for no auth. • After auth is obtained, a corrected claim or a call to overturn the

denial is necessary. • That process is time consuming, double time wasted, and will cause

extra delays. At that point the Plan doesn’t consider it a clean claim and it can drag on for months

• Direct impact on cash flow which is preventable

17

Misc other issues • Patients Plan changing during the stay

• The obvious issue of billing the wrong plan and correct plan refusing to give Retro authorization

• Facilities need an automated eligibility verification system to verify monthly the insurances your patients are on

• Not only for Medicaid HMO. This helps for Medicare Advantage plans too

• Payors in the billing system need to be set up grouping payor types, so you can easily identify MLTC, MCO, MCR HMO and Commercial payors

• Which plans are patients who are newly approved to Medicaid enrolling in?

Take control of your destiny – get involved in the enrollment process: Rate your plans Have your patients in a plan that is preferred Review this monthly in case changes in the industry will shuffle the ratings

18

When issues are not being resolved • DOH Complaint Hotline

• DOH wants to first see that you exhausted all avenues and appeals and you went thru the appeal process

• Once you have appealed the auth denial or claim denial, file a complaint with DOH.

• We have seen intervention from DOH with positive results. • MMC - managedcarecomplaint@health.ny.gov • MLTC - mltctac@health.ny.gov

1-866-712-7197 • DOH is not aware of the extent of the frustration and

mismanagement of the plans. That is because facilities are not letting them know

19

Other DOH contact info Auto Assignment Maximus - Marjorie Nesifort 917-228-5607

Billing Issues/Prompt Payment Department of Financial Services (800)-342-3736 or www.dfs.ny.gov

Complaints:

MMC Bureau of Consumer Services

managedcarecomplaint@health.ny.gov

MLTC Technical Assistance Center

(866)-712-7197 or MLTCTAC@health.ny

Denials for Medicare EOB Donna Lochner - Donna.Lochner@health.ny.gov

NYC-HRA Training: http://a069-marc.nyc.gov/marc/default.aspx

MLTC Policies: Google MRT 90

MMC Policies: Google MRT 1458

20

Comprehensive Healthcare Solutions, LLC Sandy Shur President 732-942-4558 ext 201 sandy@comphcs.com

21

Thank you.