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Medicaid Management. Stacy Calvaruso, CHAM Assistant Vice President – Patient Management, Ochsner Health System. Congressional Budget Office ……. Healthcare Reform is expected to result in Medicaid volumes growing from 39 Million to 55 Million eligible individuals by 2014.

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Medicaid management

Medicaid Management

Stacy Calvaruso, CHAM

Assistant Vice President – Patient Management, Ochsner Health System

Congressional budget office
Congressional Budget Office……

Healthcare Reform is expected to result in Medicaid volumes growing from 39 Million to 55 Million eligible individuals by 2014

Pro active approaches to upcoming medicaid changes

  • Metrics to measure success

    • Denial Reports

    • Subsequent Visits

  • Pro-Active Approaches to upcoming Medicaid Changes

    Ochsner health system

    • SE Louisiana's largest non-profit, academic, multi-specialty, healthcare delivery system

    • Named Consumer Choice for Healthcare in New Orleans for 15 consecutive years

    • Only Louisiana hospital recognized by U.S. News and World Report as a "Best Hospital" across seven specialty categories

    • 8 hospitals

    • 38 health centers in Louisiana

    • 12,500 employees

    • 850+ physicians in over 90 medical specialties

    • 300 clinical research trials annually

    Ochsner Health System

    Patient protection and affordable care act ppaca
    Patient Protection and Affordable Care Act multi-specialty, healthcare delivery system(PPACA)

    Commonly known as ‘Obamacare’

    • Effective March 2010

      • Specific provisions to be phased in thru 2020

    • Effective April 2010

      • Medicaid eligibility expanded to include all individuals and families with incomes up to 133% of the poverty level along with a simplified CHIP enrollment process.

    Patient management and mep unit

    Patient Management Division multi-specialty, healthcare delivery system

    • Hospital Patient Access Services

    • Clinic Patient Access Services

    • Pre-Service Center

      • Pre-Registration

    • Scheduling

    • Financial Counseling

    Patient Management and MEP Unit

    Swot program impact

    • Healthcare Providers should take steps to increase their understanding of how existing processes may need to be altered in this environment.

      • Develop multidisciplinary teams that are dedicated to revising key procedures.

    • As a part of overall Healthcare insurance reform programs, there will be a renewed and aggressive nature of reimbursement audits

      • Close scrutiny of the referral and authorization process.

      • Many facilities already struggle with this process and Ochsner was no different.

    SWOT - Program Impact

    Overall objectives

    • Reduced Authorization and Eligibility Denials understanding of how existing processes may need to be altered in this environment.

      • Ensure consistent financial clearance

    • Improved POS Collections

      • Pre-service patient notification and education

    • Improved Revenue –

      • Fewer delays for Financial Clearance

    • Decrease Bad Debt Volume – Proactive identification of options and resources for the patient’s out of pocket liability

      • 100% screening for Medicaid eligibility

      • Charity care based on a sliding scale

      • Prompt pay discounts

      • Propensity to pay evaluation

      • No-interest payment plans

    Overall Objectives

    1 medicaid application process

    2010 understanding of how existing processes may need to be altered in this environment. Results

    Outside Vendor

    • 6734 Applications

    • No ED Coverage

    • No Clinic Coverage

    • Very limited on-site presence

    1 -Medicaid Application Process

    Medicaid application center

    • State Certification for Financial Counselors to accept applications

    • 8A – 19P E D coverage

    • 1 year agreement with new vendor to teach us how to expand our knowledge

    • Deep Dive into demographics surrounding each facility

    • Extensive work-flow development

    • Comprehensive training

    Medicaid Application Center

    Financial counseling required

    • Pre-Service Center applications

    • Emergency Department

    • Mobile to Bedside

    • Clinical Partner

    • Various Clinics

      • Part of treatment team for high $

      • Walk-in’s

    • Open to the Public

    Financial Counseling – Required!

    Patient profiling

    • Based on data elements applications

      • Age, income, and zip code

    • Considerations

      • Estimated cost of care and patient out of pocket

      • Propensity to Pay

      • The likelihood of eligibility for financial assistance

    • Financial clearance staff provide “financial informed consent”

      • patterned after standard pre-surgical informed consent

      • seeks to educate each patient about coverage benefits

      • Other options

        • 0% Interest Payment Plans

        • Charity Care, Financial Sponsors, Community Resources, etc.

    Patient Profiling?

    Prepare for medicaid growth

    Registration applications

    • Eligibility Tool with 270/271 expanded information return

    • 3rd Party Payor Options

      • Victim’s Compensation

      • Local Charities

      • Social Security / Disability

      • COBRA

    • Profiling again… Query Medicaid

      • Medicare primary

      • Self Pay over 45 yrs old if unemployed

    • Inform patients of Medicaid enrollment opportunities

    • Prioritize screening and enrollment efforts based on expected clinical outcomes / future needs

    Prepare for Medicaid Growth

    Eligibility program results
    Eligibility Program Results applications

    The results include approvals, founds coverage and subsequent visits:


    • Number/Quantity - 15,246 approvals

    • Gross Charges - $57.9 million

    • Net Revenue - $13.3 million

    Subsequent visits
    Subsequent applicationsVisits

    Number/Quantity - 19,961 visits

    Gross Charges - $96.0 million

    Net Revenue - $21.4 million

    Program results for fy 2011
    Program Results for FY 2011 applications

    Gross Charges - $153.9 million

    Net Revenue - $34.7 million

    (net expected reimbursement) 

    Program Cost - $7.5M (est)

    2 medicaid auth task force
    2 - Medicaid Auth Task Force applications


    Understand weaknesses in current process

    Prepare for increase in Medicaid administrative paperwork

    Improve communication and accountability

    Reduce Denials

    Reduce YAA’s

    Expand to areas with missing auth related items

    Expected roi on project
    Expected ROI on project applications

    Year 1 Reduction of $9M of Gross Charges in denials

    Year 1 Reduction of $2.37M in YAA

    Savings to organization

    Year 1 = $2.2M

    Year 2 = $1.37M

    Year 3 = $853K

    Total = $4.46M

    Estimation of 60% reduction in denials over 12 month period in year 1

    based on Oct-Dec denials received.

    Savings reduced by Database & FTE salaries for 2012.

    Medicaid denials
    Medicaid Denials applications

    September thru October 2011 Results

    Top10 Denial Reasons

    Gross charges denial amount

    Medicaid denials1
    Medicaid Denials applications

    September - October 2011 Results

    Top10 Denial Reasons

    CO-140 PCP Authorization Missing/Invalid

    CO-197 Pre-Cert Authorization Missing

    Gross charges denial amount

    First step identify who does what
    First Step - applicationsIdentify who does what

    Utilization Mgmnt

    Pre-Service Center

    Admit Department

    Second step identify root cause
    Second Step – Identify root cause? applications

    Lack of Automation, Communication, and Follow-thru

    Lack of Denial data specific to PM areas

    Lack of automation

    Documentation in multiple places

    Inability to know who was assigned to a patient

    Complex rules and requirements

    Rotating staff

    Leadership challenges

    Not my job syndrome!

    2 nd step remove the excuses

    How should we resolve the issue? applications

    Use the data to determine what we are doing wrong


    Claim hold volume


    Determine who should ‘own’ the process


    Utilization Management

    Fix the problem!

    2nd Step - Remove the excuses!!

    Denial data review
    Denial Data Review applications

    All Denials received October thru December 2011

    ( Regardless of Admit Date )

    Denial data review1
    Denial Data Review applications

    Admit date priorto 10-1-11

    Denials received in October – December 2011

    Gross Denial Amount

    Team resources
    Team Resources applications

    • Map out current flow applications

    • Include key stake holders in improvement discussion

    • Identify failures without pointing fingers

    • Identify needs on how to improve

      Take Action!

    Taking action
    Taking Action….. applications

    October december denials
    October – December Denials applications

    Gross denials and the resulting YAA posted for

    DOS after October 1, 2011

    Metrics to be monitored
    Metrics to be monitored applications

    • Performance Measurement

      • Ins Ver Secure Rate (Scheduled)

      • Ins Ver Due Diligence Complete Rates (Non-Scheduled)

      • PreReg Completion Percentage

      • Ins Ver and PreReg Days Out

  • Authorizations Obtained/Completed

  • Financial Counseling Sessions Completed

    • 100% Inpatient

    • 90% Emergency Department

    • 80% Outpatients with Bad Debt and/or High Risk Score

  • B/D and Charity Care Adjustments

  • Claim Edits, Rejections, and Denials

  • Yield Affecting Adjustments

  • Lessons learned
    Lessons Learned applications

    Leveraging technology is crucial to achieving high performance

    standards in a volume-driven environment and the increase of

    Medicaid patients will impact those who are not ready.

    The lack of collaboration across service teams will negatively affect

    organizations resulting in the following:

    Loss of Revenue due to denials that result in Yield Affecting Adjustments

    Lack of automation to fully assist with cross-department work flow

    Poor communication between the various department

    Inefficiencies that result in rework across the revenue cycle

    Questions? applications