Consumer-Driven Health Plans – What Should You Consider When Choosing?

Posted on May 15, 2012 by Linda Ringquist

According to the Bureau of Labor Statistics, the combination of a pretax payment account with a high-deductible health plan is what is commonly referred to as a consumer-driven health plan (CDHP).⁷ In terms of payment methods, CDHPs are composed of a three tier payment system

A savings account
BHM Healthcare Solutions
Out-of-pocket payments
Insurance plan.

The first tier is a pretax account that allows employees to pay for services using pretax dollars. The account may be funded by the employer or the employee, depending on the type of account. The funds from this account can be used to satisfy the insurance plan deductible. The second tier is the difference, or the “coverage gap,” between the amount of money in the individual’s pretax account and the deductible. The amount that is not covered by the pretax account must be covered by the insured. If health care expenses exceed the deductible amount, then the third tier, the high-deductible health insurance plan, kicks in.

In an article from the URAC website, there are ten things to be considered when evaluating and choosing consumer-driven health plans and products.

Is the information regarding the consumer health driven plan available in a variety of formats and media? Is the information available in different languages as applicable? Is the information written in such a way that it can be understood easily, including to those who may have mental or physical impairments or disabilities?
Are all of the costs laid out in a manner in which deductibles, out-of pocket expenses, tax consequences and benefits are clear?
Does the information indicate clearly the details of the plan, including benefits and coverage, customer satisfaction results, and a directory of providers?
Is wellness and prevention data readily available and easily accessible?
Do you have access to a Health Risk Assessment which is evidence-based, reviewed by the organization’s top clinical staff, and provide feedback as to the health status and any recommendations to improve the current health status?
Does the plan provide data explaining the enrollees role and responsibility for making their own decisions for health care? Are there additional expert resources available to the enrollee to help answer any additional questions.
Are there specific instructions as to how to access assistance on a 24/7 basis through different media such as phone, email, and in person?
Is there a method for requesting a detail of the cost and quality for each provider?
Does the health plan provide assistance in making financial decisions about coverage gaps, managed care or review processes necessary for coverage and how to seek care once the personal health account has been exhausted?
Does the health plan reach out to those with chronic diseases to educate them about how to most effectively manage their health care?

BHM Healthcare Solutions specializes in URAC accreditation and URAC consulting. For more information regarding URAC accreditation assistance, please visit the URAC page of our website or call for a fee consultation call BHM at 1-888-831-1171 today!

Increased Support for Primary Care Initiatives

Posted on April 28, 2012 by Kathleen Rand

Pateints and providers fit better under medical home model.

Primary care is vital to improving care, promoting health and reducing overall system costs, yet it has been rather under-funded and under-valued in the past. A primary care practice is a key point of contact for patients’ health care needs. With healthcare reform, new ways have emerged to strengthen primary care by improving care coordination, making it easier for clinicians to work together, and enabling them to spend more time with their patients. Recently, healthcare providers have been investing in primary care.

Initiatives offered as a result of the Affordable Care Act, like Accountable Care Organizations and Patient-Centered Medical Homes will give doctors better means to work with and help patients. In fact, medical home concept has led to the introduction of a program which will allow organizations to seek specific accreditation, i.e., URAC PCHCH Accreditation program. Additionally, these programs ensure that providers can do the following:

Patient with serious or multiple medical conditions need more support to ensure they are getting the medical care and/or medications they need. Primary care practices that embrace the medical home concept will deliver intensive care management for these patients with high needs. By engaging patients directly, patient-centered medical homes and accountable care organizations can create a plan of care that uniquely fits each patient’s individual circumstances and values.
Because health care needs and emergencies are not restricted to office operating hours, medical homes must be accessible to patients 24/7 and be able to utilize patient data tools to give real-time, personal health care information to patients in need.
Primary care practices will have the ability to engage patients and their families in active participation in their care. Medical homes have the ability to centralize communication and enable providers and patients the benefit of a ‘whole picture’ approach – a patient becomes much more than a string of independent, unrelated symptoms.
Primary care is the first point of contact for many patients, and takes the lead in coordinating care as the center of patients’ experiences with medical care. Medical homes and accountable care organizations will work with the patient and his/her family to make decisions as a team. Access to and meaningful use of electronic health records should be used to support these efforts.

PCHCH Medical Homes More Prevalent

Posted on April 19, 2012 by Kathleen Rand

Model of PCHCH

URAC’s PCHCH Auditor Certification is offered to healthcare management organizations desiring to provide independent PCHCH practice assessment audits of healthcare practices. URAC PCHCH standards provide the essential foundation for providers, payers, and patients to collaborate in enhancing quality healthcare services across the continuum through shared accountability in a patient-centered health care home. URAC’s PCHCH Auditor Certification provides assurances to healthcare practices that their auditors are licensed, qualified and specially trained health professionals who understand the complexities of care coordination. The URAC PCHCH Auditor Certification requires URAC Core Accreditation, assuring that the auditing organization meets desirable standards of operation and quality management prior to performing practice audits. URAC provides the certified auditor with access to and training on tools that support verification that a practice successfully meets a baseline percentage of select URAC PCHCH essential standards.

Simultaneously, the Commonwealth Fund—a private foundation that aims to promote a high-performing healthcare system that achieves better access, improved quality, and greater efficiency—launched a four-year, $6 million initiative to help primary care safety net clinics become high-performing patient-centered medical homes. As a result, in May 2009, 68 health clinics in Colorado, Idaho, Massachusetts, Oregon, and Pennsylvania have agreed to transform the clinics into person-centered medical homes. In addition, five regional coordinating centers (RCCs) have been formed to oversee the clinic’s transformation efforts. The five RCCs were selected to participate in the demonstration project, and each partnered with about 15 preexisting safety net clinics in their state. These collaboratives will receive technical assistance on practice re-design topics such as enhanced access, care coordination, and patient experience. To be eligible for participation, partner clinics had to provide comprehensive primary care services, including preventive care and immunizations, ambulatory care, and other common services. However, clinics did not need to provide on-site mental health or dental care in order to be considered comprehensive. The RCCs receive funding from Qualis Health’s Commonwealth Fund grant.

It is anticipated that at the end of the initial grant period all 68 health clinics will be unequivocally recognized as models of excellence. The participating centers will receive training to support the health centers’ efforts to improve the coordination of information and care between primary and specialty care or community provider organizations; to use information technology to identify patients with unmet needs; to improve care for those with chronic conditions; and to systematically obtain feedback from patients for quality improvement.

Benefit of PCHCH Concept

Posted on April 14, 2012 by Kathleen Rand

We have discussed the goal of the “medical home” in the last few blog posts — improve primary care so fewer people need to go to the hospital. States experimenting with this nationwide movement say that when practiced by doctors serving Medicaid patients, it can enhance overall health conditions and consequently save billions of dollars in the long run.

But does it save money in the short term and help the financial management of healthcare organizations? Some studies reveal that patient-centered medical homes definitively showed real cost savings, even when not involved with a Medicaid program. Federal health officials are so convinced medical homes save money that they’ve offered to pay most of the bill for states to test them. Starting in 2013, states that pursue a variant of the concept, called PCHCH will get a 90 percent federal subsidy. Instead of applying medical home techniques to all patients, health homes would specialize in those with multiple chronic conditions, including mental illness.

By promoting disease management, patient education, electronic record-keeping and more personalized care, medical homes are intended to improve the lives of people with chronic diseases such as diabetes and asthma and help healthy patients prevent illnesses. Overall spending is supposed to shrink because a sharper focus on individual patients leads to fewer emergency room visits, hospital readmissions, redundant and expensive tests.

The overall sense is that the medical home model is really promising but does remain to be seen just how much money will be saved quickly. Medical homes that focus most of their resources on patients with complex cases, such as those described in the federal government’s health home program, will likely generate the biggest measurable savings. In contrast, when you look at a full panel of patients in a primary care medical home, there aren’t as many opportunities to improve care, and it’s harder to measure effects.

Whatever the studies may show, patient-centered medical homes are an undeniably appealing concept. When more emphasis is placed on primary care, health improves and overall costs go down. At least 41 states are now testing the medical home concept, and various healthcare management organizations are applying for PCHCH Accreditation which will enable PCHCH auditors to assists healthcare facilities to qualify as medical homes.

For doctors, the experiment can mean more money and the satisfaction of seeing patients do well. Instead of simply getting paid for each office visit, doctors are paid an additional monthly fee to provide better, more efficient care – a value-based purchasing extention of one of the facets of the Affrodable Care Act. And instead of handling all of their patients’ needs on their own, doctors are assisted by a team of care coordinators like caseworkers, psychologists and specialized pharmacists.

All of this takes time and money, but supporters say the results are worth it. An added bonus has been that medical homes attract more primary care physicians to the Medicaid program and, in many cases, participating doctors provide the same kind of enhanced care to all of their patients, so the entire community benefits.

PCHCH Program Accreditation – A Brief Summary

Posted on April 9, 2012 by Kathleen Rand

URAC PCHCH Accreditation Summary

Providers are always striving to improve profitability and enhance patient care. URAC’s Patient Centered Health Care Home approach can facilitate compliance with healthcare reform. Some of the aspects of this approach are streamlining coordination across the continuum of care, increasing patient access to information and boosting efficiency and effectiveness. URAC’s concept uses a step approach with high level of flexibility and customizable elements, providing educational support and cost advantages.

PCMC is a team-based healthcare delivery model led by a physician that provides comprehensive and continuous medical care to patients with the goal of obtaining maximized health outcomes. The provision of medical homes may allow better access to health care, increase satisfaction with care, and help with the financial management of healthcare.

URAC’s Patient Centered Health Care Home (PCHCH) Programs instruct and direct healthcare providers, insurers, or healthcare management consulting organizations on how to transform a practice into a truly patient centered health care home. Further, URAC’s PCHCH Achievement standards align directly with the Meaningful Use requirements, thereby promoting practice recognitions for meeting these standard elements.

The URAC PCHCH Practice Achievement Program assesses practices on key URAC PCHCH Practice Standards from the URAC PCHCH Program Toolkit. These standards are considered critical elements of a patient centered health care home and include seven mandatory standards. The standards align to the Joint Principles of the Patient Centered Medical Home and address key requirements for all Meaningful Use requirements for electronic medical records, quality data submission and e-prescribing.

To qualify for URAC’s PCHCH Practice Achievement, an organization must be reviewed on-site by a URAC PCHCH Certified Auditor or a URAC clinical reviewer. A one or two day onsite review will occur, dependent on the size of the practice. Upon successful completion, URAC PCHCH Practice Achievement is awarded for a two-year time frame.

BHM Healthcare Solutions Pursues URAC PCHCH Auditor Certification

Posted on September 21, 2011 by Danyell Jones

In July BHM Healthcare Solutions was recognized as one of four “first adopting” organizations who have already began working toward URAC PCHCH Auditor Certification. There has recently been a new approach in the marketplace for medical home recognition with the launch of URACs Patient Centered Health Care Home Programs. The URAC PCHCH Program was developed to educate and guide health care practices, and/or their sponsoring health plans, insurers, and pilot programs, as they transform into truly patient-centered health care homes. With the recent release of URAC PCHCH Practice Achievement, the demand for URAC PCHCH Auditors has grown. In July BHM Healthcare Solutions was one of four firms which were identified as “working toward URAC PCHCH Auditor Certification.”

According to URAC, the URAC PCHCH Auditor Certification is “an extension of URAC’s overall PCHCH program which will meet the needs of those entities whose responsibility will lie in independent auditing of health care home practices to determine their degree of successful achievement of the PCHCH program standards. The PCHCH Auditor Certification verifies that an organization can perform independent audits on practices against URAC’s PCHCH Practice Standards.”

Organizations who successfully meet the requirements to be PCHCH auditors will be allowed to independently audit health care practices to determine if they meet the URAC PCHCH Standards. In order to receive PCHCH Auditor Certification, an organization must first show that they themselves meet URACs stringent standards in relation to operations, training, processes, and systems. In addition, the organization must meet additional business requirements, attend specialized auditor training, and pass validation requirements. The organization must also meet all applicable HIPAA business associate requirements, and successfully undergo an evaluation in which they are tested on their understanding of the URAC PCHCH Standards.

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 PCHCH Auditor Certification, as healthcare consultants we understand the importance of URAC Certification and what it means to an organization in terms of achieving national recognition. We look forward to the process of preparing for Certification, and are excited as a team to be participating the URAC process.”

HIPAA and Privacy Violations

Posted on July 28, 2011 by Danyell Jones

As we are now exploring the issue of some of the most common healthcare compliance concerns facing organization in 2011 it is important that we examine HIPAA and the issue of privacy. HIPAA and HITECH Privacy Violations can result in both civil and criminal penalties, and it is important that HIPAA policies are followed in EVERY healthcare organization nationwide.

Maintain HIPAA Compliance

In two recent cases the cost of violating this privacy act was substantial. One organization was fined $2.25 million dollars for fail to properly dispose of protected information. Criminally more than 43 physicians have been sentenced to jail time for violations in the past five years. Here are some more interesting statistics courtesy of Liles Parker

as of mid 2010 there have been more than 93 breaches of HIPAA compliance
more than 500 individuals have been affected by these privacy breaches
The total number of individuals whose information was disclosed as a result of these breaches was estimated at over 2.5 million
of the 93 breaches, 87 involved breach of hard copy or electronic protected health information
the majority of the breaches involved theft, or loss of the records

HIPAA Compliance, one of the costliest compliance policies for healthcare organization is also one of the most important. Patient privacy will continue to be an issue of importance in the future, and only a faultless healthcare compliance program will suffice. Make sure that all members of your organization receive constant and up to date information HIPAA and any new or changing regulations, and of course seek outside assistance from a firm which is experienced with what it takes to be certified in healthcare compliance.

To learn more about HIPAA in all of its intricacies please visit the website: HIPAA Compliance

A Physicians Minefield- Section 6402 of Healthcare Reform

Posted on July 26, 2011 by Danyell Jones

Two new healthcare reform measures have recently been passed, including the Patient Protection and Affordable Care Act (PPACA) and the Health Care and Education Reconciliation Act of 2010. together these hefty volumes- more than 900 pages in all- constitute quite a weighty legislative tome, but buried inside all of this text are several very weighty anti-fraud and theft measure, proving once again that governments aim is hitting healthcare hard from a fraud and abuse perspective.

Section 6402(h)(1) is one of the most worrisome sections of this legislation because it affords the right of the Secretary to suspend all Medicare/Medicaid payments to any provider against whom a “credible allegation” has been made. Of course what is considered “credible” is not defined in any of the pages presented.In essence any organization, or individual who is a healthcare provider, upon facing any type of “credible allegation” will no longer be able to receive any type of Medicaid/Medicare reimbursement…..a reimbursement that accounts for more than 58% of an average practices revenue stream. Allegations need not be for fraud, if a provider fails to notify the state of a change of address, fails to “fully cooperate” during a site visit, or is accused of incorrect coding and/or billing all payments may be suspended effective immediately. This means that any physician or organization could face indefinite suspension pending an investigation….not a conviction….an investigation….and could be forced out of business due to the lost revenue.

Another potentially dicey section is 6402(f)(2) which was written as a preventative measure against kickbacks, and improper referrals. Unfortunately the new legislation can hold a person who “had no knowledge of this law, no intent to commit a violation of this law, and was not directly involved in the violation” responsible

We strongly recommend that all organizations have a compliance program in place, and that this healthcare compliance program continually reviews the latest laws and regulations pertaining to the industry.

Staff Inclusion, or a Hefty Fine

Posted on July 26, 2011 by Danyell Jones

How certain are you that none of your staff members have recently been excluded from Federal Healthcare Programs? This is a question that many healthcare executives and CEOs need to be asking themselves.

Recent healthcare reform has expanded permissive exclusion authorities, and many are predicted the heaviest exclusion rates in decades in the upcoming years. both Health and Human Services and the Office of Inspector General are actively reviewing providers to see if they have been excluded, and if one of these individuals is a member of your staff, you could pay hefty fines. According to a recent online article “HHS-OIG announced that it had assessed significant civil monetary penalties against a healthcare provider that employed seven individuals who the provider ‘knew or should have known’ had been excluded from participation in Federal health care programs. These individuals were alleged to have furnished items and services for which the provider was paid by Federal health care programs.”

Is a member of your staff on the list?

To make sure that your organization is fully aware of compliance in healthcare, and all that that entails, your compliance officer should screen all members to see if they have been excluded from Federal Programs on a frequent and regular basis. Screenings should be conducted against not only the HHS and OIG databases, but also the GSA databases. for more information please visit the link below:

OIG Exclusion Program

RAC Audits and Risks- Top 5 Tips

Posted on July 25, 2011 by Danyell Jones

RAC audits are now permanent and prevalent across every state and will begin to initiate reviews this year. It is a great time to make sure that your organization is compliant with all applicable regulations and billing/coding issues. A recent study found that at the average healthcare organization only 58% of services were properly coded, while 28% were over-coded and 15% were under-coded. If your organization is within this average it could spell trouble, and now is the time to look for a firm who is experienced with compliance in healthcare to assist you in readiness.

Here are our top 5 hints for making sure that your organization would be RAC Audit Ready

1. Internal Audit- conduct an internal audit of your organization to show that you are committed to the effort of submitting complete and accurate claims to payer, and identify any problems early before someone else does

2. Independent Audit- have an independent company conduct an audit of your organization to make sure that external findings support your own audit findings

3. EMR Coding/Documentation Review- Evaluate the impact that your EMR system is having on your coding and documentation

4. Know your Numbers- organizations are most often targeted for audit based on utilization rates, prescribing practices, and billing/coding practices. Make sure that you know the numbers of your organization in order to evaluate your risk early

5. Hire a Dedicated Compliance Officer- we can not stress enough how important it can be to have an individual who is certified in healthcare compliance on staff. A compliance officer can work with senior members of your organization to ensure that you are prepared for an unannounced audit or investigation.

Compliance in healthcare can be a potential minefield for individuals and organizations, but with a little bit of preparation and a strong focus on compliance, coding, billing, and documentation you can be sure that you are prepared.