PRESENTED BY: Aaron Sorensen, MBA, CPO, LPO O and P Billing Solutions, Inc.

PRESENTED BY: Aaron Sorensen, MBA, CPO, LPO O and P Billing Solutions, Inc.

What is the Affordable Care Act? (aka Obamacare) What is it driving on the consumer side? What is happening on Provider side? Future?

What is Affordable Care Act (ACA)? According to government website www.medicaid.gov: The Affordable Care Act actually refers to two separate pieces of legislation the Patient Protection and Affordable Care Act (P.L. 111-148) and the Health Care and Education Reconciliation Act of 2010 (P.L. 111-152) that, together expand Medicaid coverage to millions of lowincome Americans and makes numerous improvements to both Medicaid and the Children's Health Insurance Program (CHIP).

HHS.gov states: The Affordable Care Act is working to make health care more affordable, accessible and of a higher quality, for families, seniors, businesses, and taxpayers alike. This includes previously uninsured Americans, and Americans who had insurance that didn t provide them adequate coverage and security. So what was the timeline for its implementation and where are we today?

According to HHS.gov These are the main points, more detail can be obtained on website HHS.gov 2010: A new Patient's Bill of Rights went into effect, protecting consumers from the worst abuses of the insurance industry. Costfree preventive services began for many Americans. 2011: People with Medicare became eligible for key preventive services for free, and also received a 50% discount on brandname drugs in the Medicare donut hole. 2012: Accountable Care Organizations and other programs help doctors and health care providers work together to deliver better care. ***How many of us as providers received this help? 2013: Open enrollment in the Health Insurance Marketplace began October 1st.

From HHS: 2014: All Americans will have access to affordable health insurance options. The Marketplace allows individuals and small businesses to compare health plans on a level playing field. Middle & low-income families tax credits that cover a significant portion of the cost of coverage. And the Medicaid program will be expanded to cover more low-income Americans. All together, these reforms mean that millions of people who were previously uninsured will gain coverage, thanks to the Affordable Care Act.

2014 cont. Increasing Access to Medicaid. Americans who earn less than 133% of the poverty level (approximately $14,000 for an individual and $29,000 for a family of four) will be eligible to enroll in Medicaid. States will receive 100% federal funding for the first three years to support this expanded coverage, phasing to 90% federal funding in subsequent years. Effective January 1, 2014.

According to HHS Current 2015 IMPROVING QUALITY AND LOWERING COSTS Paying Physicians Based on Value Not Volume. A new provision will tie physician payments to the quality of care they provide. Physicians will see their payments modified so that those who provide higher value care will receive higher payments than those who provide lower quality care. Effective January 1, 2015.

Provider concerns: State by state Medicaid provisions Not all states participating in ACA same Majority of O and P practices are small business, family owned business Unofficial reports from O and P industry show 200+ independent companies have merged, folded or been acquired last 3 years How well are these remaining companies (O and P) networked? Why is this important in regards to ACA? Illustrated next several slides>

Old payment systems: care coordination (quality care as defined by Gov t) wasn t rewarded financially. New system (ACA) - Medicare s shared savings program changes to reward physicians for high-quality care and prevention Driving PCPs into ACOs This is where the patients are being seen for front end care, Primary care Gate keeper model **ACO discussion next set of slides Specialty groups forming ACOs i.e. - Large orthopedic groups Hip and knee replacements On December 22, 2014 CMS announced that 89 new Accountable Care Organizations (ACOs) will be joining the Medicare Shared Savings Program (Shared Savings Program). With that announcement, CMS will have a total of 424 ACOs participating in the Shared Savings Program in 2015, serving more than 7.8 million beneficiaries. ***Later slides shows details of projections

What are ACOs? They are intended to incentivize doctors and other providers to work together to provide more coordinated care to patients. ACOs agree to take responsibility for: the cost and quality of their patients care to improve care coordination and safety, and to promote appropriate use of preventive health services. And when this new care model saves the Medicare program money, that savings is shared with the ACO. ACOs are estimated to save the Medicare program up to $940 million in the first four years

ACO Accountable Care Organization PCP led most likely Will include specialists May have different makeup/structured for referrals May have specialty groups for referrals Based on diagnosis codes! Databases available Google for multiple resources http://www.cms.gov/medicare /Medicare-Fee-for-Service- Payment/sharedsavingsprogram /Downloads/ACO-Contact- List.pdf

So last slide said: May have specialty groups for referrals Based on diagnosis codes! What does this mean to you? Bundled payments for care EX: Knee replacement: course of treatment is decided before pt even has surgery Surgeon Surgery center/hospital #Days in hospital #Days in SNF Which SNF #Days for out-pt PT PT group Not factored in: Leg length discrepancy? Drop foot? Other medical issues that arose not from surgery: i.e. Pt fell off toilet in hospital hitting head and hurting back Completely threw the course of treatment needed off!!! Required additional documentation for treatment Additional meetings between SNF and PT administration for care with ACO Not smooth care for this pt! Not easy for the O and P provider to assist with care, even if contracted!

The Affordable Care Act also ties Medicare Advantage bonus payments to the quality of coverage these private plans offer. Gov t definition of quality? Care coordination! Cost savings! As result, in 2013, the 14 million Medicare beneficiaries currently enrolled in Medicare Advantage have access to 127 four- and five-star plans (Gov t rated), which is 21 more high-quality plans than were available in the previous year.

PROGRAM SIZE 404 Shared Savings Program ACOs and 19 Pioneer ACOs 7.92 million assigned beneficiaries in 49 states plus Washington, DC and Puerto Rico DEMOGRAPHIC DATA min median max ESRD 0.2% 0.8% 4.5% Disabled 4.0% 13.8% 55.3% Aged (Dual and Non-Dual Eligible) 44.0% 85.4% 94.5% Male 35.4% 42.5% 55.3% Female 44.7% 57.5% 64.6% Age less than 65 4.9% 16.8% 57.2% Age 65-74 (Pioneer data is non-esrd) 19.9% 42.6% 55.6% Age 75-84 (Pioneer data is non-esrd) 10.9% 27.2% 37.6% Age 85+ (Pioneer data is non-esrd) 4.1% 12.3% 30.3% http://www.cms.gov/medicare/medicare-fee-for-service- Payment/sharedsavingsprogram/Downloads/PioneersMSSPCombinedFastFacts.pdf

REPORTED COMPOSITION (Shared Savings Program only ACOs Percent Networks of Individual Practices 225 56% Group Practices 149 37% Hospital/Professional Partnerships 136 34% Hospital employing ACO professionals 103 25% Federally Qualified Health Center 47 12% Rural Health Clinic 35 9% Critical Access Hospital 31 8% http://www.cms.gov/medicare/medicare-fee-for-service- Payment/sharedsavingsprogram/Downloads/PioneersMSSPCombin edfastfacts.pdf

REGIONAL DATA -- ACOs and Assigned Beneficiaries (Note: An ACO may be in multiple regions.)--region Assigned Beneficiaries % of Medicare ACOs 1 - Boston (CT, ME, MA, NH, RI, VT) 44 858,380 29.2% 2 - New York (NJ, NY, PR, VI) 60 784,488 14.3% 3 - Philadelphia (DE, DC, MD, PA, VA, WV) 59 776,747 14.5% 4 - Atlanta (AL, FL, GA, KY, MS, NC, SC, TN) 109 1,282,599 11.2% 5 - Chicago (IL, IN, MI, MN, OH, WI) 88 1,556,674 17.3% 6 - Dallas (AR, LA, NM, OK, TX) 54 634,376 10.8% 7 - Kansas City (IA, KS, MO, NE) 31 459,432 18.8% 8 - Denver (CO, MT, ND, SD, UT, WY) 12 139,845 8.6% 9 - San Francisco (AZ, CA, HI, NV) 49 641,674 8.9% 10 - Seattle (AK, ID, OR, WA) 7 143,213 6.5% Counties with less than 1% of an ACO's assigned beneficiaries 642,460 TOTAL 7,919,888 http://www.cms.gov/medicare/medicare-fee-for-service- Payment/sharedsavingsprogram/Downloads/PioneersMSSPCombinedFa stfacts.pdf

What does all this mean for us? More patients being covered BUT More gatekeeper control for referrals ACO model Regulation/incentives for cost containment Possible fewer referrals for ancillary services Even fewer referrals for independent ancillary providers not tied into the circle of ACOs

Provider Current contracts may have ACA members included already TN: BCBS Network S Medicare replacement policies with different Payers May have new product offering for ACA members TN example New network P Have to have new contract/provider status May be contracted with Large O and P provider already Network closed

Provider Target ACO membership Be aware of different product offerings with contracted Payers Be aware of current contracts and changes i.e. payment reductions TN BCBS: 30%+ reduction TN: BCBS only exchange provider TNCARE/Medicaid BCBS big enrollment numbers Direct affect of ACA

Providers Make sure your billing staff educated and trained!!! Do not assume coverage as in-network or historical coverage of product/service Internet benefit coverage not always detailed enough Pre-cert becomes a friend! Month to month benefits Grace period to pay premium until 10 th of month!!!!! Provider could get contingent benefit info

Providers May look to be a subcontractor Team up with Rehab hospital/groups O and P Payer networks Ask do they have ACO contracts/coverage? POMAC HomeLink Linkia (Hanger owned) New emerging groups? Know where your state falls in regards to expansion of Medicaid services/enrollment

Summary Research your state participation with ACA regulations Stay in tune with your current payers Educate your billing staff Short term business plan changes Long term business plan changes Aaron J. Sorensen, CPO, LPO asorensen@rhs-tn.com Ph-(877) 907-4180

O Freedom Innovations thanks you for your continued support and hopes this series of webinars helps you make decisions to be successful in today s unforgiving O and P industry. Aaron Sorensen, CPO, LPO President, OPBS asorensen@rhs-tn.com Ph. 877-907-4180 O Please provide feedback to your Freedom sales representative of future topics to cover and if you find these webinars helpful. Rob Cripe VP Global Marketing rcripe@freedom-innovations.com Ph. 949-544-7916