2016 AND BEYOND: INCREASE YOUR SELF INSURED OPPORTUNITIES THROUGH INNOVATIVE COST-CONTAINMENT & CREATIVE ALTERNATIVES

Transcription

1 2016 AND BEYOND: INCREASE YOUR SELF INSURED OPPORTUNITIES THROUGH INNOVATIVE COST-CONTAINMENT & CREATIVE ALTERNATIVES Presented By Adam V. Russ, Esq. CEO April 4, 2016

2 Learn OVERVIEW The Future f Self Funding Invlves Prvide Guidance & Knw Yur Data Plan Plan Dcument Design Save "True" Claim Payment (Negtiate, Sign Off, Cst +) & Recvery ptins Prtect Avid Fiduciary Liability while Defending the Plan & Patient 5 Millin New Emplyee Lives Cming t Self Funding in 2016

3 OVERVIEW Preparatin - Plan Design, Internal Prcess Setup, and Data PD Wrding t Reduce Plan Csts, EOBs, Yur Templates New Overpayment Opprtunities Thrugh Data Mining Transferring Fiduciary Duties t Neutral Third Party Pre-Service - Cntrl Steerage & Incentivize Cst Cntainment "Max Allwable" Map t Determine Maximum Payable t Each Facility Direct Prvider Cntracting & Narrw Netwrks Pre-Payment - Obey the Plan & Keep Bth Eyes Open Supprting RBP Thrugh Plan Defense, Patient Advcacy & Negtiatin Alternatives t Lw Discunts and Anti-Audit Clauses f Wrap Netwrks Pst-Payment - Keep (r Take Back) What s Yurs & Prepare a Defense Hidden Subrgatin via Txic Trts, Rx & Prduct Recalls and Class Actins Medicare COB and Obtaining Overpayment Reimbursement frm Prviders

4 Ok... I m sld n Self-Funding. Why wuld I select a TPA instead f an ASO? Data Yu (Nt the ASO) Own It... Use It! Design Stay Away frm the Ckie Cutter Duty Selective Transfer f Sme (Nt All) INNOVATE! OVERVIEW Be an Advisr nt a Brker r Administratr New Pricing Optins PEPM, % f Savings, Outcmes Identify Stp Lss Incentives - $ Back t Plan?? D What the ASOs Can BUT WON T D Thrugh Data Mining, Predictive Mdeling & Cst Cntainment

5 PREPARATION Transferring Fiduciary Duties t Neutral Third Party Plan Appinted Claims Evaluatr Third Party Fiduciary Re Final Internal Appeals Prir t External Review Only the Final Appeal & Respnse is the Decisin that is Scrutinized! On Appeal, Ensuring Plan has Prcessed Claims Crrectly Facilitating & Funding IRO Appeal if Necessary Appealing Stp-Lss Denial if Necessary Independent Cnsultatin & Evaluatin Nn-Fiduciary Guidance Prvided Regarding all Plan and Plan Administrative Matters Binding, Final Authrity Remains with Plan Administratr

6 PRE-SERVICE "Max Allwable" Map t Determine Maximum Payable t Each Facility Use Data and IRS Sectin 501[c][3] and 501[r] t Rank Prviders Many Facilities are Nt Cmpliant with Sectin 501[r] Early Interventin if a Patient Requests Pre-Cert Educate Participants & D it Again (and Again) Incentives t Make a Cst-Cnscius Decisin (Carrt) vs. Patient s Respnsibility fr Excess Balances (Stick) Supplement Yur Prvider Map with Actual Charge Data Over Time t Blster the Metrics and Prepare fr Next Time Identify Key Players with Whm t Pre-Negtiate Based n Needs & Experiences

7 PRE-SERVICE Direct Prvider Cntracting & Narrw Netwrks Identify Needs (Type & Gegraphy) as well as Prviders Favrable t Medicare/Cst+/RBP Frnt-End Negtiatins with Prviders Best Suited t Treat Imminent Care r Put Knwn Treatment Needs Out t Bid Examine fr Reasnableness (f Planned Prcedure, Likely Csts, Etc.) Re-Evaluatin f Utilizatin Cmpared t Incentives Ding Enugh t Direct Steerage?

8 PRE-PAYMENT Supprting RBP Thrugh Plan Defense, Patient Advcacy & Negtiatin Reference Based Pricing Prtectin SPD, ID Card, EOB & Template Crrespndence Emplyer & Emplyee Educatin Plan Defense Against Balance Bill Appeals by Prvider and Patient Negtiatin & Direct Cntract (RBP Desn t Wrk in a Vacuum) Attempt Was Made t Cntract with Nn-Cntracted Prvider Chsen by Patient? Cntacted Prvider(s) Pre-Service t Discuss Plan Parameters and Prvider Willingness t Accept? Make Team Including Stp Lss Aware f Situatin if High Dllar Ptential Prvide Supprt, Tls fr Self Defense, and Funding fr Legal Aid Independent f the Plan!

9 PRE-PAYMENT Alternatives t Lw Discunts and Anti-Audit Clauses f Wrap Netwrks Unwrap Yur Plan Manage Participant Behavir, and Dn t Accept Abusive OON Rates r Wrap Discunts! Avid using wrap netwrks with unfavrable payment terms Achieve significant discunts n egregius r imprperly-billed claims Utilize existing claim negtiatin framewrks t supplement an existing netwrk Experience a new type f wrap, withut the netwrk Flag Large Dllar Claims, Stp Payment & Cntact Prvider

10 POST-PAYMENT Hidden Subrgatin via Txic Trts, Rx & Prduct Recalls and Class Actins Use All Data Surces: Curt Dckets Scial Media (Facebk, Twitter, Etc.) Industry Databases Such as ISO Increase Yur Data Transfers Frm Mnthly t Daily All Claims...Nt Just Paid Select Vendrs wh Specialize in Tracking Opprtunities Wrk w/ Experts t Install & Mnitr fr Key Items Secure and Prvide Data (Histrical & Rx) fr Scrubbing Preparatin fr Pssible Denials Based n SPD Third-Party Liability Language & Cmmunicatins With Members f the Same Investigate Liability Already Accepted by Third Parties t Ensure they Pay Primarily

11 POST-PAYMENT Medicare COB and Obtaining Funds frm (as well as fr) Medicare COB & Recvery Language in SPD Custm Recvery Letters Keyed t SPD & Applicable Rules Enlist Spnsr / Emplyer in Mnitring when Ptentially Medicare Eligible Participants Recently Underg Care Secure & Share Data w/ Third Party Expert fr Scrubbing Audit Paid Claims t Recver Overpaid Funds Withhld Payment fr Details if Pssible Certificatin & Utilizatin Review Teams are Aware Refer Recverable Claims t Experts t Recup

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