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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
The Patient Protection and Affordability Care Act (PPACA)
  • Medicaid Application Processing
      • External Vendor
      • Internal Processes
    • Financial Counseling
    • Patient Profiling
    • Emergency Department Focus
  • 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 (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

  • 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

    • 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


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

  • 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

    • 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


  • 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

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

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

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


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

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

September thru October 2011 Results

Top10 Denial Reasons

Gross charges denial amount

medicaid denials1
Medicaid Denials

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 - Identify who does what

Utilization Mgmnt

Pre-Service Center

Admit Department

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

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?

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

All Denials received October thru December 2011

( Regardless of Admit Date )

denial data review1
Denial Data Review

Admit date priorto 10-1-11

Denials received in October – December 2011

Gross Denial Amount

Map out current flow
  • Include key stake holders in improvement discussion
  • Identify failures without pointing fingers
  • Identify needs on how to improve

Take Action!

october december denials
October – December Denials

Gross denials and the resulting YAA posted for

DOS after October 1, 2011

metrics to be monitored
Metrics to be monitored
  • 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

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