Healthcare update 2
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Based on misconceptions regarding the exchanges and healthcare reform I created a presentation that covers some of the basic issues and actions to consider.
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Más de Jose Ivan Delgado, Ph.D.
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Healthcare update 2
- 1. Healthcare Update challenges and opportunities Taino Consultants Inc. Dr. Jose I. Delgado
- 2. Main Topics • Affordable Care Act – Exchanges • Insurance Products and Patient Responsibility • Action Items for CY 2013
- 3. Exchanges • What are the exchanges • Products • What does it means to you
- 4. What are the Exchanges? • Online shopping marketplace (i.e. Amazon) • Type of Exchanges – – – – State Federal Hybrid Commercial
- 6. Products • Plans defined by Insurance Companies – Healthcare Professionals and Organizations may not be participating in all Plans/Products – Plans have controls on who they want to participate – Closed Networks • Patients Shopping based on price – Lower Monthly = higher out of pocket – Lower monthly = restricitve Networks
- 7. Companies and average changes (FL)
- 8. Local Plans Individual Family Monthly Cost $500 - $700 $1,200 - $1,600 Co-pay Primary $50 - $100 $50 - $100 Co-pay Specialist $50 - $100 $50 - $100 $6,000 $8,000 Deductible
- 9. Higher co-pays and deductibles means • Patients increased financial responsibility – Most of the money will be collected from the patient – More cash, checks, credit cards transaction in the office – Best and most efficient method to collect is at the office – More questions from patients as they may not understand their costs and coverage – Potential higher costs for billing Companies
- 10. Risks of cash • Re-education of patients • Difficulty on receiving payment from individuals • Theft • Costs
- 11. Other Issues to consider • In/out of Network – Smaller Network easier to manage • Allowables – Fee schedule – Contract fees (beware of “based on …….”) • Cost of doing business – Overhead rate? – Cost of your services? • Cost of sending invoice?
- 12. Risk and Reimbursement • Affordable Care Act provides consumers with 90 days to go without paying their premiums and not lose coverage – Insurers don’t have to process claims – Providers must continue to offer services without payment • Lower Reimbursement from Exchange Products – For example: BC/BS of Illinois premiums are 20-30% lower – Increased volume doesn’t equal increase reimbursement
- 13. What does it means to you • Business Operations changes – Cash fail safe operations – Cost increases? • Relationships (Peers, Networks) – Return on investment? • Marketing – Pick you clients/take control – Be Proactive It is not business as usual!
- 14. ACA Compliance more than Insurances • OIG compliance plan required – Conduct audit – Develop Policies and Procedures • OIG Sanction list http://oig.hhs.gov/exclusions/ – Train staff – Document actions
- 15. Meaningful Use beyond EHR • Audits – Random and conducted by CPA firm – Documentation needed – Failure one item requires return of incentive • Interaction with other laws – False Claims Act (30 day window to return money from discovery) • Action Items – Risk Analysis – Documentation
- 16. HIPAA Security – Omnibus Rule • Business Associate Contracts – Obtain assurances • • • • Risk Analysis Risk Management (policies and procedures) Breach Response & Breach Notification Training
- 17. Summary • Significant changes that will affect all aspect s of the Healthcare Business • Healthcare and Professionals must take control to survive – Consider key aspects: • • • • Return on Investment Income Generating Activities Marketing and selecting right patient mix Risk and required actions
- 18. Dr. Jose I Delgado 904-794-7830 DrDelgado@Tainoconsultants.com www.tainoconsultants.com
Notas del editor
- Exchanges are online portals where people can compare and buy health coverage, similar to the way many travel websites are set up today. Some exchanges are public, run by the federal or state governments, and others are private, run by private companies like insurance carriers or brokers. Basically exchanges are an online marketplace/a website where shoppers can research all their options and then buy health insurance. The Affordable Care Act requires every state to offer an exchange to its residents. States have a few options: A state can choose to create and run its own exchange. If a state decides not to run its own exchange, residents of that state can shop on an exchange that will be run by the federal government. Or a state can partner with the federal government. In a partnership model, the state and federal government share responsibility for operating that state’s exchange. Private exchanges are run by private groups or companies, like a broker or health insurance company. They will run similarly to public exchanges with the biggest difference being financial assistance to pay premiums which is only being offered through the public exchanges.
- To help make shopping easier, health plans on a public exchange will be labeled platinum, gold, silver or bronze. The metallic level helps shoppers understand the level of coverage a plan offers – how much they will need to pay and what the plan pays. Platinum plans will have the lowest out of pocket cost for members but the monthly premiums will generally be higher. Bronze plans, on the other hand, will have the highest out of pocket costs for members, but will typically feature lower monthly premiums. All plans on an exchange have to offer some core benefits – called “essential health benefits” - like preventive and wellness services, prescription drugs, and coverage for hospital stays.