Healthcare Update challenges and opportunities Taino Consultants Inc. Dr. Jose I. Delgado
May 07, 2015
Healthcare Updatechallenges and opportunities
Taino Consultants Inc.
Dr. Jose I. Delgado
Main Topics
• Affordable Care Act – Exchanges• Insurance Products and Patient Responsibility• Action Items for CY 2013
Exchanges• What are the exchanges• Products• What does it means to you
What are the Exchanges?
• Online shopping marketplace (i.e. Amazon)
• Type of Exchanges– State– Federal– Hybrid– Commercial
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
Companies and average changes (FL)
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
Deductible $6,000 $8,000
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
Risks of cash
• Re-education of patients• Difficulty on receiving
payment from individuals• Theft• Costs
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?
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
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!
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
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
HIPAA Security – Omnibus Rule
• Business Associate Contracts– Obtain assurances
• Risk Analysis• Risk Management (policies and procedures)• Breach Response & Breach Notification• Training
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
Dr. Jose I Delgado904-794-7830
www.tainoconsultants.com