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Payor Summit April 2, 2010. © South Carolina HFMA - All Rights Reserved. Medicaid Update. Managed Care. Managed Care. Purchase Effective June 1, 2010. Managed Care. Carolina Crescent members will auto-convert into Advanced Total Care

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payor summit april 2 2010
Payor SummitApril 2, 2010

© South Carolina HFMA - All Rights Reserved

Medicaid Update

managed care3
Managed Care

Purchase Effective June 1, 2010

slide4

Managed Care

  • Carolina Crescent members will auto-convert into Advanced Total Care
  • Members will have the option to move from June 1st until August 18th
  • Members opting to move during June will not convert until July 1, 2010
  • Non-pars with Absolute will be paid as participating
  • No special prior authorizations for new converts (usual medical necessity continue to apply)
  • Patients inhouse on May 31 will complete the stay and be billed as Carolina Crescent members
  • Guaranteed continuity. Contact Roy Hess directly with problems
managed care5
Managed Care

June 1, 2010

Absolute Total Care

19%

managed care6
Managed Care

June 1, 2010

Absolute Total Care

39%

managed care7
Managed Care

Total Managed Care/MHN 68%

Total FFS 32%

managed care8
Managed Care

December 19, 2008 DSH Audit Rule

  • Settled to cost in DSH UPL
slide9

Managed Care

Reminders:

Out-of-network proviso

  • No longer requires MCOs to pay fee schedule on out-of-network claims (“swung both ways”)
  • Can contract for independent services outside of traditional managed care contracts
fee for service
Fee For Service
    • Current rates imitated October 1, 2009
    • October 1, 2010 based on FY 2009 RCCs using October 2009 to June 2010 paid claims data
  • Separate Lab fee schedule begins October 1, 2010
    • Will result in changes to current fee schedule and multipliers
staff education
Staff Education

SCDHHS Website http://www.scdhhs.gov/whatsnew.asp

slide13

DSHfunctional

  • 12-19-08 DSH Audit Rule
    • Due from Clifton Gunderson January 31, 2010, still not completed
    • 2007 still due from CG September 30, 2010
    • Collecting 2007 and 2008 data from hospitals together
    • Other states
slide14

DSHfunctional

  • 2010 DSH
    • Distribution originally to conform to DSH Rule guidelines
      • MCO netted to cost
      • New uninsured definition
    • Have created large variances from last year
slide15

DSHfunctional

  • 2010 DSH Reviews
    • No SCHA Audit
    • SCDHHS Managed care review delayed for additional data requests
      • Remove zero-paid claims
      • Exclude Health Connection Kids (SCHIP MCO claims)
      • Exclude Medical Health Network (MHN) claims
      • Remove lump-sum adjustments
      • Plans to review remaining large variances
slide16

DSHfunctional

  • 2010 DSH Reviews
    • Variances in uninsured UPL submissions $30m in charges, $10m in cost (+7.8 to -4.2)
    • Only reviewing increases
    • 56 requests
      • IP over $500k
      • OP over $500k
      • Newly qualified hospitals
don t shoot the messenger

Don’t Shoot The Messenger

Presented by: Barney Osborne, SCHA

slide18

DSHfunctional

Last minute revisions

  • DMH shortfall due to new uninsured definition
    • Primarily exhausted benefits due to long stays
  • Hospital ER impact
  • Revert to 2009 uninsured
    • Submit “justifiable denials”
      • Exhausted benefits and pre-existing conditions
      • Can’t include denials due to lack or precerts or billing errors
      • Can’t include untimely filing denials
    • Still settle Medicaid MCOs to cost but dual eligibles have been removed from the calculation
medicaid budget20
Medicaid Budget
  • 2010 rates saved by ARRA extension
  • 2011 Budget
    • Potential up to 20% rate decreases
      • no more stimulus
    • No progress at legislative level
this and that
This and That
  • Medicare charity care audit denials
  • JAR and Annual Hospital Financial Data Report
    • Due March 31, 2010
    • Need volunteers for Report Task Force
  • Hospital input on Worker’s Comp professional reimbursement
  • Free Value Based Purchasing financial and tracking worksheets and training available
slide24

SOUTH CAROLINA HOSPITAL ASSOCIATION

  • Preparing Medicare impact analysis
  • Free PowerPoint Presentations
    • Hospital staff and board
    • Community
    • Train the trainer sessions
  • Board and staff presentations as available
  • Contact Lara Hewitt 803.744.3518

Health Care Reform:How Will it Change the Delivery System?

questions
Questions

Barney Osborne

bosborne@scha.org

803.744.3544