BHM Healthcare Solutions Pursues URAC Independent Review Organization Accreditation

Posted on October 24, 2011 by Danyell Jones

BHM Seeks IRO Accreditation

BHM Healthcare Solutions, a nationally recognized healthcare consulting firm, is pleased to announce that they have begun to work toward URAC Independent Review Organization (IRO) Accreditation. As a consulting firm which provides a variety of services, BHM understands that it can best meet the needs of its clients, as well as strive towards ensuring that their program meets nationally recognized standards by pursuing accreditation.

BHM Healthcare Solutions is pleased to announce that they are pursuing URAC IRO Accreditation in order to establish that they meet nationally recognized standards and the goals set forth pertaining to:

Decreasing the risk of conflict of interest
Ensuring access to actively practicing expert physicians
Adhering to demanding state and federal specific review timeframes
Meeting requirements for state specific physician licensure review
Ensuring that ongoing quality improvement is taking place regarding network provider patient safety events
Ensuring that there are no issues regarding potential billing non-adherence; and
Ongoing analysis of proposed treatment to current scientific literature, FDA approved treatment and evidence based guidelines

“BHM has long strived to provide superior customer services, products, and solutions for our clients. Pursuing URAC IRO Accreditation is one more step toward adhering to the highest quality standards available for Independent Review Organizations, and we are pleased to have the opportunity to work toward achieving URAC Accreditation,” stated Danyell Jones, Director of Customer Solutions at BHM.

According to URAC, “URAC’s Independent Review Organization (IRO) standards assure that organizations that perform this service are free from conflicts of interest, establish qualifications for physician reviewers, address medical necessity and experimental treatment issues, have reasonable time periods for standard and expedited reviews, and appeals process. An organization with this URAC accreditation strives for a fair and impartial review process that is of benefit to both patients and physicians with grievances.”

URAC, an independent, nonprofit organization, is a leader in promoting health care quality through accreditation, achievement, and certification programs. URACs standards keep pace with the rapid changes in the health care system, and provide a mark of distinction for health care organizations to demonstrate their commitment to quality and accountability. BHMs CEO, Mark Rosenberg has stated that “we are very excited as an organization to begin to work toward URAC IRO Accreditation, as healthcare consultants we understand the importance of URAC Accreditation and what it means to an organization in terms of achieving national recognition. We look forward to the process of preparing for Accreditation, and are excited as a team to be participating the URAC process.”

Government Slams Medicaid Fraud But Commercial Carriers Exposed

Posted on October 19, 2011 by Kathleen Rand

Many Facing Charges of Medicaid Fraud

Department of Health and Human Services (HHS) and the Department of Justice (DOJ) teamed up in 2009 to reduce instances of healthcare fraud and abuse in Medicare and Medicaid. In fact, on September 7th, HHS and the DOJ announced that 91 people in eight cities were facing charges for their alleged participation in a variety of Medicare fraud schemes involving nearly $300 million — about $263.6 million in false billings and another $30 million in fraudulent claims.

But, according to some health plan investigators, federal and state investigators could do a better job of sharing information that could help identify fraud on the commercial side. Commercial carriers will more than likely become easy targets as the federal government focuses on fraud in Medicare and Medicaid.

The National Health Care Anti-Fraud Association (NHCAA) sponsors three meetings a year where health plan representatives from around the country discuss the types of fraud and abuse cases that they are encountering. The goal is to help detect possible schemes with in the commercial carrier world. Furthermore, there is software available that is sophisticated enough that it allows health plans to analyze claims data for outliers and can, in effect, indicate potential fraud and abuse.

But the medical loss ratio (MLR) provision of the healthcare reform law could restrict commercial health insurers and their efforts to identify fraudulent claims before they get paid. The Affordable Care Act classifies fraud and abuse prevention as an administrative expense. However, those expenses can be offset by any money recovered. So why prevent fraud? It seems there is more financial incentive to let the money go and then recover it later.

The HHS/DOJ Health Care Fraud Prevention and Enforcement Action Team (HEAT) is clearly chasing down Medicaid fraud and abuse, leaving the commercial carriers exposed in several ways and for many reasons. Systemic fraud, in which a medical provider might try to justify misrepresentation on claims as being what is best for the patient, are far more difficult to prove while Medicaid cases can be viewed as more straightforward. Further, higher unemployment and more people with no coverage seem to have caused an increase of illegal use of health insurance identification numbers, emerging elaborate fraud schemes, and a spike in violence related to fraudulent activities.

Unfortunately the economy might force otherwise honest people to perform questionable abuses of the system. But it can also encourage people to pay greater attention to where every dollar goes and report potential fraud cases immediately. The following video is an informative clip, showing how all of us can be mindful of fraud and begin to protect ourselves: http://www.wisconsinsmp.org/2011/02/video-avoiding-medicare-and-medicaid-fraud-and-abuse/

Building State Exchanges – And the Challenges

Posted on October 17, 2011 by Kathleen Rand

Commonwealth Fund Image for Insurance Exchange

One of the challenges in building the new state insurance exchanges under the Affordable Healthcare Act for state insurance commissioners and stakeholders will be to guard against unplanned consequences. The possibility that the exchanges could end up with a lopsided share of high need enrollees, while the young and healthy are able to find less costly coverage outside these exchanges is a significant threat to overall success.

The following are the major obstacles state regulators and other stakeholders must overcome to ensure the success of insurance exchanges:

(1) Adverse selection: Coverage options available within the exchanges must be attractive to and affordable for individuals and small employers in order for them to be economically worthwhile. Regulation of insurers — both on and off the exchanges —will be the deciding factor for every state in determining whether their exchange becomes a viable entity. If an exchange is left with too many potentially expensive enrollees, then two parallel, unrelated markets will spring up.

(2) Eligibility: Most states will need to develop and implement an eligibility system for not only their exchanges but for their Medicaid program as well. It would be rather easy to simply determine eligibility for exchange enrollees but Medicaid users cannot be ignored. This translates into coordination with older, legacy systems that are not all that flexible, or put another way a lot of discipline and planning to encompass Medicaid eligibility.

(3) Legacy Medicaid systems: Technology developed for the exchanges will have to allow members to easily switch between Medicaid and subsidized coverage as eligibility status changes. Also, it will need to transmit and receive data from HHS regarding subsidies and citizenship status as well as collect and remit premiums. The IT for the exchanges will need to incorporate the ability to determine eligibility and administer health benefits beyond Medicaid. Safeguards will be necessary to keep enrollees in a medical home and not have them moving from plan to plan because of income eligibility changes.

(4) Federal deadlines: While the exchanges must be operational by January 1, 2014, set up and testing must be completed before that. The federal timeline is rather aggressive, and it will be a challenge for every state. Even by compressing preliminary stages, there is little time for pilot implementations to test exchange rules and functionality. The need to meet timelines established by the Affordable Care Act has created a “monumental task” for states. Further, political unanimity must be established among all stakeholders, but sometimes people work better under tight deadlines.

(5) Momentum: Some states’ legislatures meet only every other year, so it’s crucial that legislation is enacted this session to illustrate to the federal government that they are serious about moving forward. Maintaining forward momentum is necessary to ensure eligibility for the next round of federal grants that will be used to build out the exchange.

(6) State mandates: The basic benefit package needs to be consistent across states. Once the mandatory package is clearly defined, then decisions about additional state-mandated benefits can be possible. It will be important to keep in mind that everything added will increase the cost of the premiums, and that anything not included in the federal requirements will have to be paid for by the state or the consumers.

(7) Business model: Before the framework can be developed, states must first recognize the needs among individuals and small employers and then decide how the exchange can meet those needs. Planning funds are being utilized to develop and test business models as well as corroborated planning between Medicaid and states. Further a public stakeholder process will assess ideas.

(8) Brokers: Enrollees and small employers will need assistance traversing the exchanges. In the end it will be the brokers who will serve a vital role in the development of the exchanges, and they will need to be compenated for their services so they will be willing to help consumers and employers.”

(10) Care delivery: The exchanges must do more than just enroll members in coverage. States cannot just deliver insurance but rather offer an adequate provider work force who can address people’s health needs. States should not forget the public health and prevention factor of healthcare reform, and hence focus on an integrated approach in order to make the delivery of care more efficient.

Reliance on Medicaid Managed Care Grows

Posted on October 16, 2011 by Kathleen Rand

According to a new national survey, more and more states are relying on Medicaid managed care plans, and the federal healthcare reform law hasn’t even been fully implemented yet. These states anticipate turning to Medicaid managed care organizations (MCOs) as a way of handling budgetary pressures as well as dealing with the estimated 16 million people — most of them uninsured adults — that will be added to Medicaid between 2014 and 2019 under the Affordable Care Act rollout.

In fact, the Kaiser Commission on Medicaid and the Uninsured released a report on September 14, 2011, stating that 27 of 45 states responding to their survey stated that they will undoubtedly depend more heavily on Medicaid managed care in the near future. Further, ten states reported specific plans to expand Medicaid managed care to new geographic areas or populations, such as medically compromised and the fragile elderly. Some say they mean to move Medicaid recipients with fee-for-service (FFS) coverage into managed care plans over the next few years.

It’s all about the money – it is just more economical to begin the conversion of the Medicaid population to managed care sooner rather than later.

However, the Kaiser Report cautions that Medicaid managed care may fail as a strategy without several factors in place: (a) a well thought out shift from FFS to managed care, (b) provider networks that are adequate in size, (c) sufficient capitated payment rates for plans, and (d) proper state oversight. The survey found most states include a pay-for-performance feature in their payments to Medicaid plans, and 11 states have a minimum medical loss ratio requirement for such plans.

Some pertinent points from the study are:

•Nearly every state has a comprehensive Medicaid managed care program, including primary care case management (PCCM). These cover about 66% of all beneficiaries nationally as of October 2010. Only three states (Alaska, New Hampshire and Wyoming) do not have any Medicaid managed care. Of the remainder, 36 states with comprehensive managed care programs partner with risk-based MCOs to cover 26 million-plus Medicaid recipients. 31 states run a PCCM program for 8.8 million enrollees. A dozen states use only PCCM; 17 states use MCOs only; and 19 states use both.

• 27 of 45 states expect to depend on Medicaid managed care to a greater extent. Of these 27, six (California, Kentucky, Louisiana, Michigan, New Jersey and South Carolina) say they will dictate managed care enrollment for additional Medicaid populations.

• Progressively, states are mandating managed care for those recipients of Medicaid that were previously excused from or not qualified for the program. This includes children with disabilities who are getting Supplemental Security Income (SSI) and disabled Americans who aren’t dually eligible.

•Twenty states (of 30 respondents) say they assume that managed care plans will be able to handle the imminent flood of new Medicaid enrollees under the healthcare reform law. Medicaid eligibility will expand to cover nearly all non-elderly Americans with annual incomes below 133% of the federal poverty level starting in 2014.

According to the report, Medicaid plans’ level of interest in joining state-based health insurance exchanges as defined under healthcare reform is rather uncertain. Further, an ambiguity seems to exist as to whether states will require Medicaid plans to participate in exchanges.

Meg Murray, CEO of the Association for Community Affiliated Plans (ACAP), a group of 58 not-for-profit Medicaid-focused plans, believes that the vast majority of ACAP’s member plans are interested in getting into exchanges. But in reference to ACAP’s lack of support of states that mandate plans’ involvement in exchanges, she states “it’s such a heavy lift with respect to reserves, accreditation and licensing as well as network development.”

It remains to be seen whether the Medicaid system can in fact handle the influx of now uninsured and the individuals converting from FFS programs, and whether states will formulate a definitive plan for Medicaid programs to either enter into the exchange programs or not. Needless to say, the Affordable Care Act’s overarching impact, quite clearly, has not even been fully realized, and in the meantime the urge to be reactive in the planning stage could be quite appealing.

ACA – Paved with Good Intentions…

Posted on October 10, 2011 by Kathleen Rand

Affordable Care Act Paved with Good Intentions

ACE- Paved with Good Intentions

The idea behind the Affordable Health Care Act (ACA) is noble and true. The implementation may be a bit more complicated. Public opinion has shifted and health care premiums, according to the Kaiser Family Foundation, have already risen – an increase of 9% over last year, or as Politico stated: as much as a new car.

Yet, the White House is still claiming the law will lower premiums. From http://www.whitehouse.gov/: “Independent experts have found that the new law helps reduce costs for families and businesses, cuts the deficit and strengthens Medicare, adding years to the trust fund while maintaining seniors guaranteed benefits.”

That is not the reality at this point. And when you consider the $500 billion cut from Medicare, you have to wonder: what’s going on?

First, there are expensive requirements of the ACA that have already taken effect. However, the key provisions – the ones that the supporters claim will drive costs down – do not become effective until 2014. Some of these include coverage for young adults 26 years old and under, accepting patients with no pre-conditions, and abolishing annual caps.

Again, good ideas that potentially can provide some long term benefit but three years is a long way off. Furthermore, Health and Human Services Secretary Kathleen Sebelius instituted a rule that would permit the administration the ability to “establish procedures for federal and state insurance experts to scrutinize premiums” starting in September of this year. Managed care companies were told they would have to justify any rate increases above 10%. The Sebelius rule allows HHS to question any insurance agency about its paperwork.

Coincidentally, the Kaiser study showed that premium increases came in at 9% since the passage of the ACA – just under 10%.

Insurers have pushed up costs for many reasons – for instance, the anticipation of an influx of new and possibly sick patients and also to avoid getting audited by the Obama administration before the review period kicks in.

If insurers are required to cover patients regardless of pre-conditions and the number of healthy people who sign up for the exchanges decrease, services will have to be cut in order to make a profit, affecting quality of and access to care.

So, premiums are going up, despite what the White House claims. This is bad for businesses; many won’t be able to afford to cover you or your co-workers, calling into question the President’s claim you can keep your doctor.

As former Democratic National Committee Chairman Howard Dean: “Most small businesses are not going to be in the health insurance business anymore after this thing goes into effect… That’s going to be the biggest boost to small business that has been done in years and years and years.”

Well, actually, the cost of private insurance will be moved onto the public balance sheet, making the cost of the ACA bigger, and letting

ACA- A Long, Hard Road

the taxpayers – including many of those small business owners – foot the bill.

Though the President has claimed that the ACA would bring down costs, grow jobs and help maintain the best care possible by expanding access, its consequences have not quite synced up with the expectations, not exactly what was imagined. And with the Supreme Court involved as well as the many lawsuits filed by individual states, it appears healthcare reform –whether you believe it to be ‘historic legislation’ or ‘socialized medicine,’ promises to be a long, hard road.

The Affordable Care Act – The Communication Obstacle

Posted on October 6, 2011 by Kathleen Rand

Over the next three years, as part of the ongoing healthcare reform initiative the Affordable Care Act (ACA) will be rolled out. As this

Communication Obstacles in healthcare reform

Affordable Care Act- Obstacles

unfolds, America’s state and local officials will then be charged with responsibility of reaching out to more than 30 million individuals in order to enroll them in publicly funded or subsidized health plans. These plans will be offered through state insurance exchanges.

Unfortunately, the majority of those individuals have very little knowledge of health coverage and will have difficulty finding, understanding, and using the insurance information that is necessary to getting properly enrolled.

Failure to meet the enrollment goals, however, will undermine the success of the new health law, and, more importantly, will not increase health insurance coverage. Steps need to be taken to clear up the language and procedures surrounding the enrollment process. Otherwise individuals will more than likely not enroll. A roadblock which will amount to a significant waste of time, energy, and taxpayer dollars.

Properly enrolling in a health insurance plan, particularly a government funded or subsidized plan (such as Medicare or Medicaid), is a complicated undertaking. Individuals must find their way through a maze filled with eligibility guidelines, forms to complete, and lists of mandatory citizenship and financial documentation required for enrollment. Needless to say, if the information is not clear and usable, people will get lost and stalemated.

Additionally, they need to understand concepts such as premiums, co-pays, and benefits, and then apply this comprehension to their existing health situation so that they can choose the most appropriate plan. In short, they must figure out which services are covered and which are not, and complete additional paperwork to enroll in a plan they select.

My head’s spinning just thinking about it. And research proves an even larger issue: Fourteen percent of US adults have trouble finding the date of a physician’s visit on an appointment slip. According to the National Assessment of Adult Literacy, only 12 percent can successfully compute their contribution toward health insurance costs, even when a table is included to facilitate the analysis.

Clear communication is the only hope for the success of the Affordable Care Act to enroll those newly eligible in an appropriate insurance plan. We cannot rely upon a website and assistance from insurance exchange counselors alone. These insurance counselors themselves have to be fully articulate in the language and literacy barriers facing many of those individuals now able to obtain coverage. Even now, state Medicaid programs do not successfully enroll all eligible populations. 88 percent state enrollment is considered highly successful, while the least successful states enroll just 44 percent of those who qualify for services.

The Affordable Care Act does require health plans that are seeking certification in state exchanges to provide information in plain language. This means, according to the ACA, using “language that the intended audience, including individuals with limited English proficiency, can readily understand and use because that language is concise, well-organized, and follows other best practices.”

But is this a reality? One obvious obstacle is the up-front expense of creating insurance information and enrollment processes that use clear, accessible language. However, not making the enrollment process understandable to people of all literacy levels will be even more costly.

A system that is difficult to figure out equals delays in enrollment or failure to enroll at all in any health plan, particularly individuals who are healthy and feel less pressure to have insurance coverage. If these individuals remain un-enrolled, the majority of the individuals participating in the exchange market will be sicker (or higher risk), resulting in higher costs for health care overall.

Proactive measures need to be taken to support individuals through the enrollment process. Assistance with completing the application can be provided by community-based organizations and health providers as well as by the exchange counselors. Low health literacy has to be considered a factor in healthcare reform and actions to eradicate it have to be in place for the Affordable Care Act not to fall short of expectations.

Affordable Health Care Act: In A Nutshell

Posted on October 5, 2011 by Kathleen Rand

Affordable Care Act In a Nutshell

Simply stated, it is an act to provide affordable, quality health care for all Americans and reduce the growth in health care spending. But as all of us know, nothing is ever that simple. In this blog, we will briefly examine the Act itself, and in subsequent blogs, we’ll explore obstacles and opinions regarding the Affordable Health Care Act and how it plays an integral part in healthcare reform overall.

The Affordable Health Care Act, part of overall healthcare reform, attempts to restructure certain aspects of the private and public health insurance programs. A major goal of the Act is to crack down on some of the most egregious practices of the insurance industry while simultaneously putting some control of health coverage and care back into the hands of consumers.

Some of the central changes made by the legislation include:

health insurers can no longer refuse or drop coverage based on patients’ medical histories or because of a pre-existing condition
health insurers cannot charge different rates based on patients’ medical histories or gender
establishing minimum standards for qualified health benefit plans
young adults can remain covered under parents until age 26
most employers must provide coverage for their workers or pay a surtax on the workers wage up to 8%
an expansion of Medicaid to include more low-income Americans by increasing Medicaid eligibility limits to 150% of the Federal Poverty Level and by covering adults without dependents as long as either or any segment doesn’t fall under the narrow exceptions outlined by various clauses throughout the proposal
a subsidy to low- and middle-income Americans to help buy insurance
a central health insurance exchange where the public can compare policies and rates
requiring most Americans to carry or obtain qualifying health insurance coverage or possibly face a surtax for non-compliance
a 5.4% surtax on individuals whose adjusted gross income exceeds $500,000 ($1 million for married couples filing joint returns)
inclusion of language originally proposed in the Tax Equity for Domestic Partner and Health Plan Beneficiaries Act
inclusion of language originally proposed in the Indian Health Care Improvement Act Amendments of 2009

An awful lot of information, I know. In a nutshell, The Affordable Care Act arose for many reasons, not the least of which is the prevalence of health care fraud and abuse, but the intention seems to be to ‘bring peace of mind to millions who are one accident or illness away from medical and financial chaos.’ Further, according to the New Patient’s Bill of Rights on http://www.healthreform.gov/, the Act will reduce the ‘hidden tax’ on insured Americans, will improve American’s health, and will enhance workers’ productivity.

The Act will take several years to be rolled out, but, in the meantime, opinions for and against – not to mention lawsuits, abound. In the coming days, we’ll review the varying opinions about and obstacles facing this legislation.

BHM Featured at NC TIDE Conference

Posted on October 3, 2011 by Danyell Jones

BHM Healthcare Solutions, commonly recognized as one of the nation’s best behavioral health consulting firms, is proud to announce

Join BHM in Asheville NC for the NC TIDE Fall 2011 Conference

that two organizational members will be featured speakers at the upcoming NC TIDE Conference in Asheville, NC occurring November 13^th through the 16^th 2011. NC TIDE, which stands for training, instruction, development, and education, is a bi-annual conference that includes staff from all aspects of the Mental Health, Developmental Disabilities, and Substance Abuse Services field. This year’s fall conference will be held in Asheville, NC and is expected to draw more than 400 participants from LMEs, provider organizations, and state offices. NC TIDE hopes to provide information that the Sate, LMEs and providers need to improve performance in all areas and at all levels.

As part of the NC TIDE Conference BHMs Senior Vice President of Finance and Claims, Brian Johnson, will be hosting a session entitled “Using Financial Data for Making Management Decisions.” This talk is targeted at those who wish to learn more about the financial management of healthcare. Attendees will learn why financial data is important, how to utilize trend analysis, and gain a comprehensive understanding of the different IBNR models and how to utilize them to make impactful decisions.

Joining Mr. Johnson will be Connie Coburn-Smith, a senior consultant with BHM and URAC accreditation specialist. Mrs. Coburn-Smith will be hosting two talks, the first of which is entitled “Performance and Progress: the Basics of CMS Quality Framework.” This session will be focused on quality improvement for healthcare and attendees will learn about the CMS Quality Framework and why it is important for their organizations. Building on this talk, a second presentation will be made entitled “Quality Improvement Projects: Keys to Success.” This quality improvement focused presentation will instruct attendees on how to effectively target quality improvement gaps and make the necessary changes.

BHM Healthcare Solutions is extremely pleased and honored to be featured presenters at this falls NC TIDE Conference and would like to encourage anyone to attend by registering at http://www.nctide.org/

To learn more about select BHM Quality Improvement programs, initiatives and trainings please visit http://www.bhmpc.com/quality-improvement/