Maximizing Revenue and Minimizing Cost Training Sponsored by Tribal Self-Governance Advisory Committee Arlington, VA Myra M. Munson, J.D., M.S.W. Sonosky,

Maximizing Revenue and Minimizing CostTraining Sponsored by

Tribal Self-Governance Advisory CommitteeArlington, VA

Myra M. Munson, J.D., M.S.W.Sonosky, Chambers, Sachse, Miller & Munson LLP

May 7, 2014

[email protected]

Maximizing Revenue and Minimizing CostWebinar Presentation Sponsored by

Tribal Self-Governance Advisory CommitteeArlington, VA

Myra M. Munson, J.D., M.S.W.May 7, 2014

[email protected]

Washington, DC Juneau, AK Anchorage, AK Albuquerque, NM San Diego, CA

Sonosky, Chambers, Sachse, Miller & Munson, LLP302 Gold Street, Suite 201, Juneau, AK 99801

907-586-5880

Where to Start – Consider Roles

Tribes juggle many roles:• Tribal government• Health provider• Employer

OBJECTIVE: To maximize revenue and minimize costs associated with health care, while achieving governmental objectives of improving the physical, spiritual, and economic well-being of members and community.

TSAGC Webinar May 7, 2014 Maximizing Revenue and Minimizing Costs Slide 3

Sonosky, Chambers, Sachse, Miller & Munson, LLP302 Gold Street, Suite 201, Juneau, AK 99801, 907-586-5880

Tribal Opportunities: As a . . .• Health Provider

• IHCIA § 206 – Third Party Recovery• IHCIA § 401 – Reimbursement from Medicare, Medicaid & CHIP• IHCIA § 408 – Right to Reimbursement from Federal Programs,

including VA and DoD under § 405(c) • ARRA § 5006 – Medicaid Cost-Sharing Protection• ACA §§ 1402(d) and 2901(a) – Exchange Plan Cost-Sharing Protections• IHCIA § 813 – FTCA for Services Provided to Non-Beneficiaries• Electronic Health Record Incentive Payments• ARRA § 5006 – Deemed Participating PPO by Medicaid Managed Care

Plans and BBA of 1997 – No Mandatory Enrollment of AI/ANs in Medicaid Managed Care Plans

• ACA § 2202 Medicaid Presumptive Eligibility by Hospitals

TSAGC Webinar May 7, 2014 Maximizing Revenue and Minimizing Costs Slide 4Sonosky, Chambers, Sachse, Miller & Munson, LLP

I/T/U Roles and Opportunities

• Purchaser of Health Services/Contract Health Services • ARRA § 5006 and ACA §§ 1402(d) and 2901(a) – Cost-Sharing

Protections• ACA § 2901(b) – Payer of Last Resort (25 U.S.C. § 1623(b))• MMA § 506 – Medicare Like Rates

• Purchaser of Health Coverage for IHS Beneficiaries• IHCIA § 402 – Authority to Purchase Coverage or Health Services • ACA Exchange Plan Coverage• Medicare Part D• ACA Exchange Plans


Sonosky, Chambers, Sachse, Miller & Munson, LLP

I/T/U Roles and Opportunities

• Provider of Health Coverage for Employees (Indian and Non-Indian)• IHCIA § 409 – Federal Employee Health Benefit Plan• ACA Medicaid Expansion• Direct Delivery of Services

• Advocate for AI/ANs

AND, most of these lists are not complete!!!There are other opportunities.



But, Let’s Focus

Most rights are not self-enforcing.

Generating revenue and achieving savings require affirmative action and constant monitoring.

No one part of the Tribe can do the work in isolation from the rest.



Do You Know Who Is an “Indian” for What Purpose?

See, Handout:Indian Health Services, Medicaid,

Affordable Care Act:Who is Eligible for What?



Questions?

This is your first chance; there will be others.



You Can’t Collect, If You Don’t Bill

Must haves:• Billing system or contractor• Trained staff – coding, compliance, providers,

billers• Good negotiators• A business focusAnd, even then there are challenges



Sec. 206 THIRD PARTY RECOVERYS. 1790 S. 125; 25 U.S.C. § 1621e

*Right to recover reasonable charges (rather than reasonable expenses) or highest amount the payor would pay a non-governmental provider• from insurance companies, HMOs, employee benefit plans, and tortfeasors, and any other responsible or liable third party• Allows THOs to use the Federal Medical Care Recovery Act• Allows self-insured tribes to authorize payment to IHS• Allows THO to recover costs and attorney’s fees if prevailStatus: Tribal health programs are increasingly aware of the importance of pursuing recovery as required by law; many insurers are unaware of the rules or actively resist. Litigation occurring to enforce tribal rights.



Some Insurers Don’t Want to Pay

ANTHC v. Premera

Federal District Court for Alaska ruled on Summary Judgment motion that if an Indian tribe agreed to accept payments lower than its billed charges by contract (for example, discounting for preferred provider status), then the payment contract controls.



What If There Is No Contract

In the absence of a payment contract, the Court also ruled that the Indian health program is entitled to the higher of:

(1) its reasonable charges or (2) an amount higher than its reasonable charges to the same extent non-governmental providers are entitled to receive that rate. Minimum payment under Alaska insurance regulations (80th percentile of charges in the geographic area) was the example used by the Court in its decision.



What Hasn’t Been Ruled On

There is no ruling yet on the extent to which (if any) insurers can reduce payments because the Indian health program is not part of its preferred network (some reduce by as much as 60%) (Premera, for example). We think this is impermissible since Section 206 (1) allows recovery of “reasonable charges billed,” not discounted “out of network” rates, and (2) Section 206 covers managed care organizations, which by definition require individuals to stay in network (argument not made yet and not rules on yet).



What’s Likely to Happen

This litigation will take time. Efforts at mediation failed completely. Premera is simply not accepting the Court means what was said in the summary judgment ruling. It has filed two more motions trying to get the case dismissed.

In the meantime, there has been discovery, and may still require further litigation about the facts, more motion practice, and possibly appeals.

Don’t hold your breath!



What Can You Do?

Keep billing (or start if you’ve stopped). You won’t get paid if you don’t file a claim.

Keep charges up-to-date. Charges are usually higher than what insurers pay routinely. You won’t know what the insurers are paying others, but you can know about your own charges.



What Can You Do? continued

Work claims. Denials are being routinely issued by some insurers that count on the Indian health system being too overwhelmed to refile and demand payment.Do not enter into any form of contract unless you are willing to accept the payment rates. The District Court for Alaska has ruled that if you’ve agreed to certain rates, you are stuck with them.



What Can You Do? continuedRead and review ALL the terms of any Agreement with an Insurer. Be sure the agreements do not have other terms that compromise the Indian health program or Tribe.

And, this includes the CMS Tribal Addendum.

Although there is a lot in it that is really helpful, there are provisions that may be problematic for your tribe.

IF YOU SIGN AN AGREEMENT, BE SURE YOU ARE PREPARED TO LIVE WITH IT.



Using Cost Sharing Protections to Generate Revenue and Achieve Savings

• IHCIA Sec. 4(5) defines “Contract Health Services” (CHS) to include referrals without commitment to pay, as well as those where there the I/T/U will take responsibility for payment.

• No Medicaid Premiums or Cost Sharing – ARRA 5006; 42 USC 1396o(j). • AI/ANs referred by CHS to any provider are not responsible for any cost

sharing.• The provider payment may not be reduced by the amount of the cost sharing.• Applies to Medicaid Expansion

• Cost Sharing Protections under Exchange Plans – ACA §§ 1402(d) and 2901(a): Must verify status with each plan and potential covered person• Indians under 300% of poverty, enrolled in any Exchange plan, are exempt from cost sharing (25 U.S.C. § 1623(a))• No cost sharing for services provided by I/T/U and no deduction in payments to I/T/U• Qualified Health Plan will be paid by HHS for the cost sharing



COST AVOIDANCEMedicare Like Rates

Basic Rule Effective July 5, 2007 – A Medicare enrolled hospital may not accept more than a Medicare Like Rate for services provided to an American Indian or Alaska Native (AI/AN) for any medical care purchased under the contract health services (CHS) program or a UIO purchase for an urban Indian. If the I/T/U has an agreement that provides for lower payment for the CHS, then the hospital must accept the lower amount.

BUT, many tribal programs are still not taking advantage of this. If not, is it too late? We don’t think so. But, there will be work involved.

• Reprice at least a sample of claims• Make a request to the hospital to work out a settlement of past claims• Follow-up if the hospital doesn’t cooperate• BEGIN REPRICING IMMEDIATELY SO THAT YOU DO NOT CONTINUE TO PAY

MORE THAN IS REQUIRED

Negotiate MLR with other providers TSAGC Webinar May 7, 2014 Maximizing Revenue and Minimizing Costs Slide 20


Don’t Leave Money on the Table!

Medicare Quality Initiatives require affirmative action – otherwise, payment levels may be reduced.

o Physician Quality Reporting System (PQRS)o Electronic Prescribing (eRX)o Ambulatory Surgery Center (ASC) Quality Reporting

See, “Reimbursement and Billing: Medicare Incentive Payments,” Presentation by Sherrie Varner, Choctaw Nation of Oklahoma, Medicare Policy Analyst & Affordable Care Implementation Team, at NIHB Annual Consumer Conference, August 2013.



Questions?

This is your second chance; there will be others.



YOU’VE GOT THE BASICS, WHAT’S NEXT?



Expand ServicesMore and Better Health Care and More $$$

ACA requires health plans to pay for more prevention and wellness• Requires plans issued after 3/23/10 to provide certain preventive

care without cost• Specified screenings for adults with certain conditions such as

high blood pressure or cholesterol, diabetes, and cancer• Increases Federal share for certain preventive services if States

do not charge co-pays• Required Medicaid to cover tobacco cessation to pregnant

womenIf you aren’t providing these services, you are missing an opportunity to improve health status and generate revenue.

TRIBAL HEALTH PROGRAMS – include all your health programs in your ISDEAA funding agreement so you get the benefit of FTCA coverage and more certain reimbursement.



More Expansion

• Serve tribal employees

• Serve other people in the community

• Expand direct services when the cost of CHS or claims exceed the cost of providing the services directly



eliminate silosinside and outside the Tribe



Employer: Consider Options

• Federal Employee Health Benefit Plan

• Risk based policies vs. self-insured coverage

• Be your own provider and keep the money within the Tribe and maximize opportunities to improve worker health



FEHB – An Option for Employee Insurance Coverage

For more information: See Office of Personnel Management, Tribal Federal Employees Health Benefits Handbook Highlights, available at http://www.opm.gov/healthcare-insurance/indian-tribes/reference-materials/handbook-highlights.pdfOPM webpage for Tribes: http://www.opm.gov/healthcare-insurance/indian-tribes/health-insurance/ Dear Tribal Leader Letter: http://www.opm.gov/healthcare-insurance/indian-gtribes/hr-personnel/outreach-documents/122011letter.pdf (Dec. 21, 2011)Frequently Asked Questions: http://www.opm.gov/healthcare-insurance/indian-tribes/faqs 2014 Rates just announced: See, http://www.opm.gov/healthcare-insurance/healthcare/plan-information/premiums/#url=Premiums TSAGC Webinar May 7, 2014 Maximizing Revenue and Minimizing Costs Slide 28


http://www.opm.gov/healthcare-insurance/indian-tribes/reference-materials/handbook-highlights.pdf

http://www.opm.gov/healthcare-insurance/indian-tribes/reference-materials/handbook-highlights.pdf

http://www.opm.gov/healthcare-insurance/indian-tribes/health-insurance/

http://www.opm.gov/healthcare-insurance/indian-tribes/health-insurance/

http://www.opm.gov/healthcare-insurance/indian-gtribes/hr-personnel/outreach-documents/122011letter.pdf

http://www.opm.gov/healthcare-insurance/indian-gtribes/hr-personnel/outreach-documents/122011letter.pdf

http://www.opm.gov/healthcare-insurance/indian-tribes/faqs

http://www.opm.gov/healthcare-insurance/healthcare/plan-information/premiums/#url=Premiums

http://www.opm.gov/healthcare-insurance/healthcare/plan-information/premiums/#url=Premiums

Tribal Health Provider

Can be part of the solution to Tribal health costs!But, you have to overcome the myths. Is it really true:• that you always have to wait for an appointment

or when you arrive for an appointment?• the quality isn’t as good as if you have private

insurance?• the services never pay for themselves?NO! But, it doesn’t matter if that is the general perception.



Employer Strategies

Avoid Penalties

• For failure to provide required summaries (up to $1000 for each plan beneficiary to whom not provided)

• For failure to offer coverage• Don’t offer too much coverage (Cadillac Plans –

beginning 2018 if value of premiums exceeds $10,200 for individual or $27,500 for family (subject to inflation adjustments), a 40% excise tax may be imposed



What If Your State Hasn’t Adopted Medicaid Expansion? BE AN ADVOCATE

1. Don’t give up. There is no deadline.2. Get your facts in line about the benefits –

economic to the State, reducing uncompensated care, and better health for otherwise uncovered individuals.

3. Get together with other advocates for Expansion and not just the hospitals.

4. Try to keep the issue alive. Don’t let it disappear.



Ideas for a Work Plan• Health planning work group: Council, Finance, Human

Resources, Health Department, legal • Catalog all health care provided: directly and through

self-insurance, CHS, extended benefits to members, purchased insurance, reinsurance

• Make a timeline of when new requirements and costs may hit so you are ahead of them

• Evaluate impact of new requirements and opportunities• Strategize options to reduce cost, improve impact of funds

spent, increase revenue• Influence policy: review all proposed State Medicaid rules

and State Plan Amendments and Comment• Don’t move to fast, but don’t wait too long!



Questions?This is the last chance for this presentation, but all questions about maximizing revenues and minimizing costs are welcome. You can also send questions via the internet on the Health Reform page for the Self-Governance Communications and Education (SGCE) website: http://www.tribalselfgov.org/____NEWSGCE/___healthcare/Blog_page/healthblog2.html



http://www.tribalselfgov.org/____NEWSGCE/___healthcare/Blog_page/healthblog2.html

http://www.tribalselfgov.org/____NEWSGCE/___healthcare/Blog_page/healthblog2.html

References

Where do I find these laws? What do the acronyms mean?



Citations for the Wonks

ACA = Patient Protection and Affordable Care Act, Pub. L. 111-148ARRA = American Recovery and Reinvestment Act of 2009, Pub. L. 1115 (Feb. 2009)CHIPRA = Children’s Health Insurance Program Reauthorization Act, Pub. L. 111-3 (Feb. 2009)IHCIA = Indian Health Care Improvement Act, Pub. L. 94-437, as amended, most recently by ACA § 10221, which enacted by reference S. 1790, as reported out of the Senate Committee on Indian Affairs in December 2009, with four amendmentsISDEAA = Indian Self-Determination & Education Assistance Act, Pub. L. 93-437, as amended



Even More for Wonks

MMA = Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Pub. L. 108-173, amending § 1866(a)(1) of the Social Security Act. See, Sec. 506, codified at 42 U.S.C. § 1395cc(a)(1)(U), and regulations found at 42 C.F.R. § 136 and C.F.R. Title 42, Part 489, provider agreements and supplier approval.



Acronyms for IHCIA and ACA

ACA = Patient Protection and Affordable Care Act, Pub. L. 111-148ARRA = American Recovery and Reinvestment Act of 2009, Pub. L. 1115 (Feb. 2009)AI/AN = American Indian/Alaska NativeAPTC = Advance Premium Tax CreditBBA = Balanced Budget Act of 1997CCIIO = Center for Consumer Information and Insurance Oversight (part of CMS; used to be OCIIO)CHIP (or CHP) = Child Health Insurance Program CHIPRA = Children’s Health Insurance Program Reauthorization Act, Pub. L. 111-3 (Feb. 2009)CHSDA = Contract Health Service Delivery AreaCMS = Centers for Medicare & Medicaid Services (agency within Dept. of Health & Human Services)EHB = Essential Health BenefitsFEHB = Federal Employee Health Benefit PlanFEGLI = Federal Employees Group Life ActFPL = Federal Poverty LevelIRC = Internal Revenue CodeISDEAA = Indian Self-Determination & Education Assistance Act, Pub. L. 93-437, as amendedI/T/U = Indian Health Service/Tribal Health Program/Urban Indian Organization



More Acronyms

MAGI = Modified Adjusted Gross IncomeMEDPAC = Medicaid and CHIP Payment and Access CommissionMMA = Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Pub. L. 108-173 (Dec.

2003)MMPC = Medicare/Medicaid Policy Committee of the NIHBNIHB = National Indian Health BoardOCIIO = Office of Consumer Information and Insurance Oversight in HHSQHP = Qualified Health PlanPCIP = Pre-Existing Condition Insurance Plan (often referred to as “high risk pool” plan)SHOP = Small Business Health Options Program TTAG = Tribal Technical Advisory Group to the CMS TrOOP = True Out-of-Pocket costs applicable to Medicare Part DUIO = Urban Indian Organization, as defined in IHCIA Sec. 4(29)VA = Department of Veterans Affairs

And, there will be lots more!



Presenter

Myra M. Munson is a partner in the Juneau office of Sonosky, Chambers, Sachse, Miller & Munson LLP, which specializes in representing tribal interests in Alaska and throughout the United States. She earned her bachelor's degree from the University of Alaska Fairbanks in 1972 and her law degree and master's degree in social work with honors from the University of Denver in 1980. After serving as Alaska Commissioner of Health and Social Services from 1986 to 1990, Ms. Munson joined the Sonosky Law Firm LLP where her practice has emphasized self-determination and self-governance, the Indian Health Care Improvement Act (IHCIA), Medicaid and other third-party reimbursement issues, and other health program operations issues. She was a technical advisor to the IHCIA National Steering Committee for over 10 years; assisted in drafting and editing substantial sections of the reauthorization; and testified before the Senate Committee on Indian Affairs. Ms. Munson is also a member of the National Indian Health Board Medicare & Medicaid Policy Committee, and a technical advisor to the Centers for Medicare and Medicaid Services Tribal Technical Advisory Group. She has been conducting extensive training on the Affordable Care Act and IHCIA since their passage and serves as a consultant to the National Indian Health Board with regard to training on and implementation of these new laws. In 2003, Ms. Munson was given the Denali Award by the Alaska Federation of Natives. and in 2009 the Healthy Alaska Native Foundation awarded her with its President’s Award.



Documents

Maximizing Revenue and Minimizing Cost Training Sponsored by Tribal Self-Governance Advisory Committee Arlington, VA Myra M. Munson, J.D., M.S.W. Sonosky,