Consulting Administration Brokerage Communications Compliance - PowerPoint PPT Presentation

Consulting │ Administration │ Brokerage │ Communications │ Compliance

About our Speaker Scott Mayer Director of Data Analytics, CrawfordAdvisors, LLC Scott focuses on helping employer groups use the vast amount of healthcare data at their disposal to identify and stratify the risk within their employee population, and develop programs and strategies aimed at controlling and containing said risk. Scott is very active in the healthcare community, having served on numerous boards and committees such as: • Executive board of the Baltimore Association of Health Underwriters • The Navigator Advisory Committee for the Maryland Health Connection, • The NAIFA-MAHU Joint Legislative Committee. His legislative efforts have garnered awards and recognition at both the state and national level. Scott holds a degree in math and physics from Cornell University, and loves the challenges of working with big data sets to develop meaningful analytics, predictive outcomes, and statistical projections for his clients. CrawfordAdvisors, LLC

Not all Services are Created Equal Basic Services: Bloodwork (Lipid Profile) Source Procedure Source Procedure Billed Amount Allowed Amount Code Description Provider ID Place of Service Description $ 1,068.00 $ 826.41 80061 Lipid Profile 1205859766 Outpatient Hospital $ 1,008.98 $ 38.08 80061 Lipid Profile 200248060 Outpatient Hospital $ 1,008.98 $ 38.08 80061 Lipid Profile 200248060 Outpatient Hospital $ 6.55 $ 6.55 80061 Lipid Profile 1134165970 Independent Laboratory $ 6.55 $ 6.55 80061 Lipid Profile 1134165970 Independent Laboratory $ 6.55 $ 6.55 80061 Lipid Profile 1205854817 Independent Laboratory $ 6.55 $ 6.55 80061 Lipid Profile 1205854817 Independent Laboratory $ 6.55 $ 6.55 80061 Lipid Profile 1134165970 Independent Laboratory CrawfordAdvisors, LLC

Not all Services are Created Equal Basic Services: Chest X-Ray Source Procedure Source Procedure Billed Amount Allowed Amount Code Description Provider ID Place of Service Description $ 1,754.00 $ 205.12 71020 Chest X-Ray-71020 1073516183 Outpatient Hospital $ 1,531.12 $ 268.74 71020 Chest X-Ray-71020 1669427258 Emergency Room Hospital $ 1,436.93 $ 23.02 71020 Chest X-Ray-71020 1063470763 Outpatient Hospital $ 21.22 $ 21.22 71020 Chest X-Ray-71020 1649220443 Office $ 21.15 $ 21.15 71020 Chest X-Ray-71020 1609865708 Office $ 21.00 $ 13.00 71020 Chest X-Ray-71020 381893379 Urgent Care Facility $ 20.99 $ 20.99 71020 Chest X-Ray-71020 1669405700 Office $ 20.33 $ 20.33 71020 Chest X-Ray-71020 1609865708 Office CrawfordAdvisors, LLC

Not all Services are Created Equal Basic Services: CT Scan (Full Body) Source Procedure Source Procedure Billed Amount Allowed Amount Code Description Provider ID Place of Service Description $ 21,445.00 $ 10,888.00 R352 CT Scan - Body Scan 582032904KENNESTONEH Inpatient Hospital $ 17,419.00 $ 9,656.00 R352 CT Scan - Body Scan 880213754RENOWNREGIO Inpatient Hospital $ 17,419.00 $ 16,281.00 R352 CT Scan - Body Scan 880213754RENOWNREGIO Inpatient Hospital $ 203.00 $ 199.00 R352 CT Scan - Body Scan 520591656JOHNSHOPKIN Outpatient Hospital $ 200.00 $ 196.00 R352 CT Scan - Body Scan 526049658GREATERBALT Emergency Room Hospital $ 198.00 $ 196.00 R352 CT Scan - Body Scan 520591531WESTERNMARY Emergency Room Hospital $ 198.00 $ 196.00 R352 CT Scan - Body Scan 520610538 Emergency Room Hospital $ 196.00 $ 192.00 R352 CT Scan - Body Scan 520591612FREDERICKME Emergency Room Hospital CrawfordAdvisors, LLC

Not all Services are Created Equal Basic Services: MRI Brain (with & w/o dye) Source Procedure Source Procedure Billed Amount Allowed Amount Code Description Provider ID Place of Service Description $ 4,960.00 $ 1,287.00 70553 Mri Brain W/O&w Dye 6490915THOMASJEFFERS Outpatient Hospital $ 4,816.00 $ 1,287.00 70553 Mri Brain W/O&w Dye 6490915THOMASJEFFERS Outpatient Hospital $ 4,810.00 $ 979.00 70553 Mri Brain W/O&w Dye 1386749893 Outpatient Hospital $ 556.00 $ 149.00 70553 Mri Brain W/O&w Dye 541098455FOUSTROBERT Office $ 551.00 $ 551.00 70553 Mri Brain W/O&w Dye 201749446MEDSOLUTION Office $ 365.00 $ 216.00 70553 Mri Brain W/O&w Dye 421066542RADIOLOGIST Office $ 365.00 $ 216.00 70553 Mri Brain W/O&w Dye 421066542RADIOLOGIST Office $ 334.00 $ 216.00 70553 Mri Brain W/O&w Dye 421009288MASONCITYCL Office CrawfordAdvisors, LLC

Unreal! What can we do about it? Tools at your disposal: Plan Design • Facility Fees • Surcharges • Tiered Charges • Reference Based Pricing Network • Narrow Networks • Exclusion from Benefits Consumerism • Deductibles/Reference Based Pricing • Apps/Websites • Advocacy Vendors • Bundled Payments CrawfordAdvisors, LLC

Reference Based Pricing Set the Benchmark: MRI Example Low Cost ($149) High Cost ($1300) Reference Price ($600) Determine a Median “Reference Price” • Reimburse a certain percentage up to the reference price • Charges over the price are member’s responsibility • Can include opportunities for shared savings CrawfordAdvisors, LLC

Narrow/Tiered Networks Drive Efficient Utilization and Reduce Costs Low Cost/Hi Regular In- Out-of-Network Benefit Quality Provider Network Provider Provider No Deductible $2000 Deductible $4000 Deductible MRI/CT Scan Plan pays 100% Plan pays 90% Plan pays 70% No Deductible $2000 Deductible $4000 Deductible IP Surgery Plan pays 90% Plan pays 80% Plan pays 60% No Deductible $2000 Deductible $4000 Deductible OP Surgery Plan pays 100% Plan pays 90% Plan pays 70% No Deductible $2000 Deductible $4000 Deductible Maternity Plan pays 100% Plan pays 90% Plan pays 60% CrawfordAdvisors, LLC

Narrow/Tiered Networks “Centers of Excellence” – Heart Attack Example https://www.medicare.gov/hospitalcompare/search.html CrawfordAdvisors, LLC

Narrow/Tiered Networks “Centers of Excellence” – Hip/Knee Replacements https://www.medicare.gov/hospitalcompare/search.html CrawfordAdvisors, LLC

Consumer Tools/Websites/Apps CrawfordAdvisors, LLC

Non-PBM Pharmacy The Large Costs Lurking in the Shadows… CrawfordAdvisors, LLC

What are J-Codes? HCPCS Codes are a Subset of the CPT Codes Healthcare Common Procedure Coding System A-codes (example: A0021): Transportation, Medical & Surgical Supplies, Miscellaneous & Experimental B-codes (example: B4034): Enteral and Parenteral Therapy C-codes (example: C1300): Temporary Hospital Outpatient Prospective Payment System D-codes: Dental Procedures E-codes (example: E0100): Durable Medical Equipment G-codes (example: G0008): Temporary Procedures & Professional Services H-codes (example: H0001): Rehabilitative Services J-codes (example: J0120): Drugs Administered Other Than Oral Method, Chemotherapy Drugs K-codes (example: K0001): Temporary Codes for Durable Medical Equipment Regional Carriers L-codes (example: L0112): Orthotic/Prosthetic Procedures M-codes (example: M0064): Medical Services P-codes (example: P2028): Pathology and Laboratory Q-codes (example: Q0035): Temporary Codes R-codes (example: R0070): Diagnostic Radiology Services S-codes (example: S0012): Private Payer Codes T-codes (example: T1000): State Medicaid Agency Codes V-codes (example: V2020): Vision/Hearing Services CrawfordAdvisors, LLC

J-Codes are Big Business HCPCS Codes are a Subset of the CPT Codes Why Hospitals are Purchasing Practices Lower Physician Reimbursements 15% 26% 6% Expansion of Infusions Centers 3% Access to Referred Infusion Patients 50% Other Don't Know Source: Magellan Rx CrawfordAdvisors, LLC

What are J-Codes? Are They Run Through PBM, or Medical Plan? HCPCS NDC HCPCS Description NDC Label INJECTION, IMMUNE GLOBULIN, (GAMMAGARD LIQUID), NON-LYOPHILIZED,(E.G. 00944-2700-02 J1569 GAMMAGARD LIQUID (PF,LATEX-FREE) 100 MG/ML LIQUID), 500 MG Discount of Hospital Medical Plan Billed Charge ASP Plus/AWP Provider Medical Plan Minus Specialty AWP PBM Pharmacy Minus CrawfordAdvisors, LLC