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Understanding the
Alphabet Soup By: Cheryl Puetz
Definitions
� ACO � MCO � IPA � Bundle Payments � Dual Eligible
ACO Accountable Care Organization
� ACO’s are groups of physicians, hospitals and other health care providers, who come together to give coordinated high quality care to their Medicare patients. By doing so, they will be eligible to share in the savings to generate a relative benchmark.
� The payment will include covered services beginning 3 days before a hospital admission and extending to 30 days after the hospital discharge on selected procedures.
� ONLY awarded by CMS
ACO’s in California � Accountable Care Clinical
Services, PC � Affiliated Physicians IPA � Akira Health, Inc. � APCN-ACO � Cedars-Sinai Accountable Care � Meritage ACO, LLC � National ACO � San Diego Independent ACO � UCLA Faculty Practice Group � ApolloMed Accountable Care
Organization Inc. � Golden Life Healthcare, LLC � John Muir Physician Network
� Meridian Holdings, Inc. � North Coast Medical ACO, Inc. � Torrance memorial Integrated
Physicians, LLC � Brown & Toland Physicians � Heritage California ACO � Healthcare Partners Medical
Group � Monarch Healthcare � Primecare Medical Network � Sharp Healthcare System � Primary Partners, LLC � AppleCare Medical ACO, LLC � Premier ACO Physicians Network
MCO Managed Care Organization
� PPO, HMO, POS, EPO, HDHP � Other wise know as commercial insurance
� Kaiser Permanente � Blue Cross/Blue Shield � United Healthcare � Aetna � Cigna � Humana � and many others
IPA Independent Physician
Association (the last GREAT FRONTIER)
� IPA is a legal entity that is organized and directed by physicians (private practice) to negotiate contracts with insurance companies.
� They have privileges at hospitals but run independently.
� They have their own case management and do their own billing.
� Many are trying to find a way to practice quality medicine in spite of the hospitals dictating mandates.
Bundled Payments for Care Improvement
� Federal programs to reduce cost and increase higher quality outcomes.
� 48 Categories of Disease states; especially for Cardiac, Respiratory, Diabetes, & GI
� Currently testing the waving of 3 night inpatient stay in hospital. Utilizing Skilled Nursing Facilities and Home Health.
http://innovation.cms.gov/initiatives/bundled-payments/
Dual Eligibles Medicare-Medical Recipients
Cal MediConnect � Goal is to improve coordination of care � Forced HMO � Complete evaluation of each case
upon enrollment. � Case Manager oversight for highest
utilization of service.
Cal MediConnect Plans by County Alameda County
Los Angeles County
Orange County
San Diego County
Alameda Alliance for Health
L.A. Care CalOptima* Care 1st
Anthem Blue Cross CareMore Community Health Group
Care1st Health Net
Molina HealthCare
Molina Health Care
Health Net
San Mateo County Riverside County San Bernardino County
Santa Clara County
CareAdvantage Inland Empire Health Plan
Inland Empire Health Plan
Anthem Blue Cross
Molina Health Care
Molina Health Care
Santa Clara Family Health Plan
*Participation pending readiness review.
MSSP
Start Date
Medicare FFS and in Medi-Cal Managed
Care (enrolled in one month)
Medicare FFS and Medi-Cal FFS (enrolled
by birth month)2
MSSP Benes eligible for Cal Medi-Connect
(enrolled in one month)
CMC DSNP / Part D
LIS Benes (enrolled
in one month)
Opt out of CMC and in
Medi-Cal FFS (enrolled by birth month)
Excluded from CMC
(ESRD, 1915c waiver, etc.) and in Medi-
Cal FFS (enrolled by birth month)
Full Duals in a CMC plan
DSNP/ any LIS reassignees in Medi-Cal FFS (enrolled in one month)
In a non CMC DSNP plan or any MA plan
sponsored by any health plan
(enrolled by birth month)4
Full Duals in Medi-Cal
managed care plan ( benefit added in one
month)1
Excluded from CMC (ESRD,
1915c waiver, etc.) and in
Medi-Cal Managed Care (benefit added in one month)1
MA benes or LIS reassignees in
Medi-Cal Managed Care (benefit added in one month)1
MSSP Beneficiaries in
Medi-Cal managed care
or Medi-Cal FFS (enrolled in one
month)
Medi-Cal Managed Care (benefit added in one month)
Medi-Cal FFS (enrolled by
birth month)2
4/14 San Mateo San Mateo
Los Angeles, Riverside, San
Bernardino, San Diego, and San
Mateo
Los Angeles, Riverside, San
Bernardino, San Diego, and San
Mateo
Los Angeles, Riverside, San
Bernardino, San Diego, and San
Mateo.
San Mateo (Full Duals in MA plan or excluded from
CMC )
5/14Riverside, San Bernardino,
and San Diego
Riverside, San Bernardino,
and San Diego3
Riverside, San Bernardino,
and San Diego
7/14 Los Angeles Los Angeles Los Angeles Santa Clara Santa Clara Santa ClaraSan Mateo
(Partials and Medi-Cal only)
Los Angeles, Riverside, San
Bernardino, San Diego, San
Mateo, and Santa Clara
8/14
Los Angeles, Riverside, San
Bernardino, San Diego, and Santa Clara
Los Angeles, Riverside, San
Bernardino, San Diego, and Santa
Clara
10/14
Los Angeles, Riverside, San Bernardino,
and San Diego
Los Angeles, Riverside, San
Bernardino, San Diego, and Santa
Clara
Los Angeles, Riverside, San
Bernardino, San Diego, and Santa
Clara
1/15Santa Clara,
Alameda, and Orange
Santa Clara and Alameda
Alameda, Santa Clara and Orange
All Eight Counties
Alameda and Santa Clara
AlamedaAll Eight Counties
Alameda Alameda and
Orange Alameda and
OrangeAlameda and
OrangeAlameda and
OrangeAlameda and
OrangeAlameda
4. Those with Aug-Oct birthdays will be enrolled Oct 2014. Nov-July birthdays will be by birth month. There are no FFS Medi-Cal enrollees in Orange and San Mateo counties.
CCI Enrollment Timeline by County and Population** Revised 6.6.14 pending DHCS proposed DSNP/MA policy**
Cal MediConnect enrollment begins in April 2014 with passive enrollment in San Mateo; and "opt-in" in Riverside, San Bernardino, San Diego and Los Angeles counties.
3. Enrollees with April and May birthdays will be enrolled in May 2014. Then follow enrollment schedule by birth month.
1. Enrollees already in a Medi-Cal managed Care plan will receive one notice prior to the change in benefit.2. There are no FFS Medi-Cal Enrollees in Orange and San Mateo counties.
MLTSS (Mandatory enrollment)Cal MediConnect (Passive enrollment)Full Duals in Medi-Cal Managed Care Partial Duals/Medi-Cal onlyFull Duals Only Full Duals in Medi-Cal FFS2
Company Analysis
How well do you STACK UP? � Medicare Compare
� http://www.medicare.gov/homehealthcompare/search.html
� Patient Satisfaction Surveys � Outcome Data (Quality Measures) � Clinical and Therapy Protocols � Utilization Patterns � ER Utilization � Hospital Readmissions
What You Need…
� Outcome Data (Quality Measures) � Clinical and Therapy Protocols � Utilization Patterns � ER Utilization � Hospital Readmissions by Disease
Are You Ready for Change? � Honest independent analysis of your agency � SWOT analysis � Do you have the right people?
� The staff you have today may not be the right staff for tomorrow.
� Train and Re-train staff � Are you really ready to make the hard
decisions and stick by them? � Are your clinicians capable of achieving the
company goals? � Are you top heavy in management?
Meeting Preparations
� How can you SAVE them MONEY & IMPROVE their outcomes.
� References (The Right Ones)
� Proof, Proof, Proof
Meeting with the RIGHT PEOPLE
� CFO � VP of Utilization Management � VP or Director of Case
Management
Tools � Therapy Utilization � Efficiency + Effectiveness = higher profitability � Sound Protocols/Clinical Pathways � Quality Measurement Programs � ER Prevention Program � Patient Retention Program � Return on Investment
In Today’s connected world of healthcare, you’re right to be concerned about HIPAA compliance. We are your partner in safeguarding healthcare information and to ensure the confidentiality and integrity of PHI (Protected Health Infor-mation). Stricter HIPAA audits are on the horizon.
THE RULE Unsecured PHI means PHI that is not secured through: encryption: and/or de-struction - as provided by HHS guidance. Methods must render PHI “unusable, unreadable, or indecipherable” to unauthorized individuals (see HIPAA Security Rule & NIST standards).
WHAT YOU SHOULD KNOW Policies without processes are nothing more than empty promises and will not prevent serious compliance liability. HHS is going to want to see evidence not only of policies but processes as well.
POLICIES + PROCESSES + TRACKING = VDE (VISIBLE DEMONSTRATIVE EVIDENCE) Given the lax enforcement of HIPAA’s Privacy & Security Rules prior to the HITECH Act, we are certain that HHS is going to have no problem finding instances of “willful neglect” – especially for those unlucky few to be the first ones audited. You need a technology partner that has a roadmap to help you navigate this maze and establish a culture of compliance in the company that you work hard to grow. Hippo Safe has the most comprehensive solution for you.
H PAA COMPLIANCE
HippoSafe your HIPAA/HITECH technology compliance partner. Call us for a FREE consultation 630.560.4888
www.hipposafe.co
Dermatology practice hit with $150,000 HIPAA fine
(American Academy of Dermatology, January 31, 2014)
Concentra Health Services has agreed to pay $1,725,220 after an unencrypted laptop was stolen from
one of its facilities. http://www.fiercehealthit.com/story/ocr-levies-2-million-hipaa-fines-stolen-
How much can you afford to lose?
Group slapped with $6.8 Million HIPAA FINE
(Healthcare IT News , February 18, 2014)
In today’s world of healthcare, you’re right to be concerned about your companies survival. We are your partner in weathering the storm.
We analyze and streamline business development, administrative, and clinical processes utilizing available technology resulting in a more effi-cient workflow thus improving:
Speed and accuracy of data Increased patient capacity without the need of additional personnel Better compliance Better quality of care Increased revenue Scalability Proven marketing plan for sustained growth
HippoSafe your guide to surviving the ACA. Call us for a FREE consultation 630.560.4888
HIPAA/HITECH Utilization Management Coding/Oasis/QA Compliance
Quality Improvement Profitability Analysis Business Development Audits Mock Survey www.hipposafe.co
Consulting Services
ACO, Bundled Payments, Utilization Management, QA & Coding
Record Net Income Loses
for the Biggest Home
Health Care Companies CMS continues to cut
Reimbursement
The Storm is Coming… How will your Home Health Survive?
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