H.R. 938 Enhancing Medicaid TPL

Transcription

1 H.R. 938 Enhancing Medicaid TPL Michele Carpenter, SVP Government Services Kristen Ballantine, VP Government Relations May 25, 2017

2 1. About HMS Agenda 2. Third Party Liability (TPL) History Legal authority Challenges remain 3. H.R. 938 Overview Benefits 4. Other considerations 5. Call to action Get involved 2

3 The leading healthcare cost containment company in the U.S. Founded in 1974 Based in Irving, Texas About HMS NASDAQ:HMSY 2,300 employees across 26 U.S. offices 100 million healthcare lives under contract Billions of dollars saved and recovered annually for Medicaid programs More than 40 Medicaid agencies and 200 Managed Care Organizations (MCOs) utilize HMS TPL services 3

4 The Only Proven TPL Solution HMS has the only comprehensive TPL solution that has been proven effective Existing data use agreements with thousands of health plans, employers Most expansive data matching logic Millions invested in TPL technology annually Large scale billing and recovery operations in place Dedicated provider and carrier relations functions Highest return on investment 4

5 Third Party Liability Solutions Cost Avoidance The broadest range of edits and match logic Employed before a service is rendered or a claim is paid Recovery Ensures Medicaid is the payer of last resort in all instances Commercial insurance Casualty Estate plan Workers compensation Dual eligible Compliance Facilitates welladministered programs Health insurance Premium payment Special needs trusts Dependent eligibility verification 5

6 By law, Medicaid is the payer of last resort, which means if a Medicaid recipient is covered by another healthcare plan or program, that plan must pay prior to Medicaid to the extent of its liability. 6

7 Why is TPL Important? An individual may have both Medicaid coverage and other private health insurance coverage Approximately 10%-13% of Medicaid members have other insurance coverage By state and federal law, all other available third party resources must be used before the Medicaid program pays for the care Every year, the Medicaid program saves billions of dollars by avoiding and recovering healthcare expenses that are the responsibility of another healthcare plan 7

8 The Legality of TPL (a)(25) of the Social Security Act Deficit Reduction Act enhancements 3. State DRA-compliant laws/regulations 4. State plan requirements 5. TPL action plans 6. Medicaid manuals 7. Waiver of requirements 8

9 TPL Successes and Challenges 9

10 HHS OIG 2013 Report HHS Office of Inspector General (OIG) issued a study of state trends in Medicaid TPL savings over a decade. Key Successes Savings increased attributable to Cost Avoidance Recoveries increased attributable to process improvements Use of contractors Advancements in HIT Improvements driven by DRA updates 10

11 HHS OIG 2013 Report Key Challenges $4 billion at risk of not being recovered. Reimbursement Identification of third parties Complete coverage data Key Recommendations Disseminate best practices Act as a liaison for data sharing agreements Address States challenges with Tricare and Medicare Working with CMS to rein in consistently uncooperative third parties Strengthen enforcement mechanisms to deal with uncooperative third parties 11

12 U.S. GAO Medicaid TPL 2015 Report Key Challenges Out of state insurers Insurer driven data matches Obtaining key data elements Timeliness of data matches Key Opportunities Best practice information sharing MCO TPL guidance 12

13 Improving and Maximizing TPL Recovery State variability Industry changes Health IT advancement Insurance consolidation Changes to delivery and payment models Adaptation to changes in the regulatory environment Lessons learned Application of best practices 13

14 H.R

15 Federal TPL Legislation Introduced Feb. 7, 2017 Sponsored by Congressman Mike Burgess (R-TX) Co-sponsored by Congressmen Flores (R-TX) and Guthrie (R-KY) Referred February 10, 2017 to the House Energy and Commerce Committee Subcommittee on Health 15

16 Captures Additional Liable Third Parties Requirement: The DRA revised definition of liable party includes self-insured plans, PBMs, and other parties that are, by statute, contract, or agreement, legally responsible for payment of a claim for a healthcare item or service. Challenge: Some liable parties refuse to cooperate. H.R. 938: Adds Tricare, fully insured plans, accountable care organizations and any other health plan determined appropriate by the Secretary to the list of liable parties. Other Considerations: Health savings and reimbursement accounts (HSAs and HRAs), third party administrators, and state high risk pools (HRPs). 16

17 Captures Out of State Insurers Requirement: Federal law requires states to enact TPL statutes and regulations in accordance with federal standards Challenge: Insurance is regulated at the state level, creating a loophole for out of state insurers H.R. 938: Closes the out of state insurer loophole Other Considerations: Aligns with intrastate insurance concepts 17

18 Codifies MCO TPL Authority Requirement: CMS sub-regulatory guidance clarifies the role of MCOs when TPL is delegated. Challenge: Some liable parties have refused to cooperate with MCOs. State DRA-compliant statutes were written prior to widespread reliance on MMC. H.R. 938: Explicitly authorizes MCOs to have the same rights as the State, including access to data and recovery rights, when TPL responsibility is delegated. 18

19 Institutes Prompt Pay Standards Requirement: Federal law allows states the flexibility to establish parameters Challenge: Few states have prompt pay standards resulting in numerous unanswered TPL claims. H.R. 938: Establishes a 60-day prompt payment standard for Medicaid reclamation claims Other Considerations: Alignment with state standards for commercial prompt payment. Imposition of uncontestable obligation if not paid timely 19

20 Prohibits Denials Related to Prior Authorization Requirement: Federal law requires states have laws in effect that prohibit insurers from denying claims submitted by the state solely on the basis of the date of submission, the type or format of the claim form or a failure to present proper documentation of coverage at the point of sale. Challenge: Many carriers deny claims because the provider did not receive prior authorization from the commercial insurer. H.R. 938: Prohibits denials for a lack of prior authorization and requires acceptance of Medicaid s medical necessity determination. 20

21 Additional Changes Grants TPL authorities, including assignment of rights to the Children s Health Insurance Program (CHIP) Eliminates CAV exclusion for EPSDT and child support Clarifies the treatment of EFMAP Standardizes CMS 64 form reporting Requires HHS to publish training, best practices and monitor challenges Subjects states to FMAP withholds for noncompliance 21

22 The Benefits of H.R. 938 Increases savings and recoveries Improves compliance Protects taxpayer funds Standardizes and unifies TPL reporting Clarifies FMAP retention for EFMAP populations Expands TPL rights to CHIP avoiding disenrollment 22

23 Other Considerations 23

24 Prohibit Out-of-Network Denials Requirement: The SSA requires states to prohibit procedural claim denials. Challenge: Insurers and employers are trending towards closed provider networks. This noticeable uptick has resulted in increased TPL claim denials due to the rendering physician being out of network. Solution: Prohibit denials based upon out of network limitations and require the liable party to at least pay the Medicaid paid amount. Benefit: Ensures Medicaid remains the payer of last resort and maximizes TPL recovery. 24

25 Limit Carrier Refund Periods Requirement: No federal requirements Challenge: Under current law, there is no timeline to govern the lookback period in instances when an insurer pays a claim and later realizes it was paid in error. There are legitimate reasons for carrier refund requests, but no statute of limitations exist subjecting the state to unpredictable refund requests. Solution: Limit the timeline an insurer can request a refund Benefit: Instills predictability 25

26 Impose Noncompliance Penalties Requirement: No federal requirement Challenge: Little recourse to noncompliance Solution: Enforceable penalties for failure to share data or honor claims processing standards Benefit: Ensures insurer cooperation with TPL efforts, leading to an increases in savings and recoveries, and more timely claims processing Example: More than 10 states have enforcement rights ranging from financial penalties to licensure suspension/revocation UT Code Ann. 31A and , and KY

27 Call to Action 27

28 Get Involved Inform and encourage support among: Agency leadership Governor s office, including D.C. office Key members of the state legislature Call/write your members of Congress Engage CMS: Leadership TPL staff TPL TAG Update your state: TPL action plan TPL statutes and regulations State plan amendment 28

29 TPL References Federal Statutes/Regulations/Guidance Summary of Statutory Requirements Summary of Regulatory Requirements Frequently Asked Question (2014) Guide to Effective State Agency Practices (2014) Guide to Effective State Agency Practices Update (2015) Reports/Other Materials HHS Office of Inspector General (OIG) Report (2013) U.S. Government Accountability Office (GAO) Report (2015) COB/TPL Training/Handbook (2016) For more information, contact: Michele Carpenter Kristen Ballantine

30 Enterprising healthcare