Carenodes Behavioral Health Case Management

ETHOS AND PROGRAM DESIGN

The central premise of the Carenodes Behavioral Health Case Management (BHCM) Program is to promote collaboration between all treating providers, ensuring coordination between medical care and behavioral health care. Once members are identified, Behavioral Health Care Managers outreach / consult with our community partners in medical and behavioral health practice settings. Our program supports the treatment planning needs of providers with respect to behavioral health services and often provides consultation/ suggestions for modifications in current care. This coordination is performed through various avenues including

  • Notification letters to physicians informing them that their patients are engaged with the program,
  • Telephonic outreach calls,
  • Opportunity/option for physician peer-to-peer consultation when needed.

The essence of behavioral health management is ensuring that we direct our members to the right services at the right time.

Our triage and tracking processes include specialized support during service level transitions, such as a discharge from inpatient to outpatient follow-up treatment to ensure that members are attending follow up appointments with community providers within 7 days of hospital discharge. In addition, we utilize a readmission risk algorithm, which identifies members most at risk for readmission to inpatient hospital care. Specialty services are also offered to members diagnosed with eating disorders, maternal mental health issues, families of children and adolescents with a recent inpatient psychiatric stay, and members referred from community providers affiliated with Enhanced Personal Health Care. Also, consenting members engaged in medical care management programs with a positive PHQ2 depression screen or any other BH condition impeding the member’s ability to manage their medical condition are routed to BH for intervention.

Clinical Team/Patient/Family Engagement

Our clinicians work with the member and their family to:

  • Understand the options available for behavioral health treatment, utilize insurance benefits for the lowest possible out of pocket cost, and decrease unnecessary health care expenditures
  • Advocate for the coordination of all care, both medical and behavioral health
  • Educate on symptoms and condition management to prevent future inpatient hospitalization stays
  • Discuss and identify barriers to treatment compliance and offer resources and support to overcome them
  • Improve overall health outcomes for improved quality of life

Effect of Care Coordination on Patients With Alzheimer Disease and Their Caregivers | AJMC

Although care coordination did not decrease overall acute health services use, coordination improved clinical documentation of patients’ memory impairment. ED visits may have begun to decrease among patients. Finally, stress levels may have fallen among caregivers.

Conclusions: Although care coordination did not decrease overall acute health services use, coordination improved clinical documentation of patients’ memory impairment. ED visits may have begun to decrease among patients. Finally, stress levels may have fallen among caregivers.

Effect of Care Coordination on Patients With Alzheimer Disease and Their Caregivers
November 3, 2020
Brian Chen, JD, PhD , Xi Cheng, MPH , Blaiz Streetman-Loy, PhD, MSW , Matthew F. Hudson, PhD, MPH , Dakshu Jindal, MA , Nicole Hair, PhD
Volume 26, Issue 11

Takeaway Points

Care coordination and caregiver support remain the primary intervention to meet the growing challenge of caring for patients with Alzheimer disease and related dementias (ADRD). Few studies, however, assessed their impact on objective measures of health care utilization. We studied patients and caregivers enrolled in the Memory Program in Greenville, South Carolina, and found strong evidence that the program led to better documentation of patients’ AD diagnosis. We also found evidence suggestive of a reduction in emergency department (ED) utilization among patients with AD and a potential reduction in urgent medical utilization for depression among caregivers.

  • Existing literature on ADRD interventions often focused on feasibility and self-reported outcomes.
  • Our studies assessed the impact of the Memory Program on objective measures of health care utilization for patients with AD.
  • The immediate impact may be better clinical documentation of AD even when patients seek care for other medical conditions.
  • There is suggestive evidence that the intervention reduced ED utilization among patients and acute medical service use for depressive symptoms among caregivers.

Read more

Statutory and Plan-Bid Components of the Regional MA Benchmarks

Carriers set their actual prices by bidding against the capitation payment amounts. Carriers with plans that do well on Medicare Advantage program quality measures get a higher monthly capitation payment.

Statutory and Plan-Bid Components of the Regional MA Benchmarks

The annual election period for 2020 coverage is set to start Oct. 15 and run until Dec. 7. The capitation payment spreadsheet below shows about how much Medicare Advantage program managers think they should be paying each month for each Medicare Advantage plan enrollee’s care.

Carriers set their actual prices by bidding against the capitation payment amounts. Carriers with plans that do well on Medicare Advantage program quality measures get a higher monthly capitation payment.

  • The 2020 county-level averages range from $755 per month, in Presidio, Texas, up to $1,609, in Nome, Alaska.
  • To simplify things, we calculated state-level averages. The 2020 state-level averages ranged from $883 per month, in Hawaii, up to $1,168, in Alaska.
  • We also calculated how fast each state’s average capitation level changed between 2019 and 2020. The year-over-year change ranged from 4%, in Delaware, up to 8.2%, in one state.

ACCESS THE 2021 MEDICARE RATEBOOK: 2021 Medicare Ratebook (National, County Level Capitation Rates)

Determining Medicare payment for regional MA plans

Aside from a few special payment incentives, payment for regional MA plans is determined like payment for local plans, except that the benchmarks are calculated differently. CMS determines the benchmarks for the MA regional plans by using a more complicated formula that incorporates the plan bids. A region’s benchmark is a weighted average of the average county rate and the average plan bid.

As directed by law, CMS computes the average county rate as the individual county rates weighted by the number of Medicare beneficiaries who live in each county. The average plan bid is each plan’s bid weighted by each plan’s projected number of enrollees. CMS then combines the average county rate and the average bid into an overall average. In calculating the overall average, the average bid is weighted by the number of enrollees in all private plans across the country, and the average county rate is weighted by the number of all Medicare beneficiaries who remain in FFS Medicare.

#CMS #FFS Medicare #Medicare #2021RateBook

Title 42. Public HealthChapter IV. CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES Subchapter B. MEDICARE PROGRAM Part 422. MEDICARE ADVANTAGE PROGRAM Subpart F. Submission of Bids, Premiums, and Related Information and Plan Approval Section 422.258. Calculation of benchmarks.

1-Minute Pro Tip: How to Handle Claim Denials from Private Insurance Companies

Before challenging a claim, examine the reason for your denial. The reason for the payer’s denial can be found on the Explanation of Benefits or EOB. In some cases, the denial may have been caused by a clerical error such as an incorrect CPT code, a missing signature, or another simple oversight.

Before challenging a claim, examine the reason for your denial. The reason for the payer’s denial can be found on the Explanation of Benefits or EOB. In some cases, the denial may have been caused by a clerical error such as an incorrect CPT code, a missing signature, or another simple oversight.


A denial of coverage because a PA performed the service is usually phrased as “service only covered when provided by an M.D. or D.O.” or “physician assistants not considered authorized providers under the plan.” In some cases, first assisting at surgery claims are denied for incorrect use of modifier codes (Do not assume that all companies use the same code; some use -AS, some use -80, -81, or -82.) and in other cases, those claims are denied because of the use of a restricted code or for performing a surgery not necessarily requiring a first assistant.


You may need to contact the insurance company to find out what modifier should have been used and, in some cases, you may need documentation that a first assistant was medically necessary for the surgery. Insurance companies strive to (1) retain their subscribers, (2) maintain or increase their market share, and (3) keep a positive corporate image. If the insurance company made the coverage decision and you believe that the coverage decision was unfair, enlist the help of the patient and, if applicable, the business that pays the insurance plan’s premium. Their dissatisfaction is

Subcontracting Opportunities

Carenodes contracts with physicians, facilities and other health care professionals to form our provider networks, which are essential for delivering quality, accessible and cost-effective health care services. In partnership with providers (medical and non-medical, behavioral, primary, substance abuse, and others), we have developed (and are growing) community-wide coalition efforts geared towards addressing larger systemic health, infrastructure or social determinant issues with a large impact on health.

Carenodes contracts with physicians, facilities and other health care professionals to form our provider networks, which are essential for delivering quality, accessible and cost-effective health care services. In partnership with providers (medical and non-medical, behavioral, primary, substance abuse, and others), we have developed (and are growing) community-wide coalition efforts geared towards addressing larger systemic health, infrastructure or social determinant issues with a large impact on health.

WORKFORCE MOBILIZATION INITIATIVE

Did you know that locating and securing subcontracting opportunities can be just as, if not more valuable, than administering direct contract awards? There are multiple ways to partner with other contractors to maximize your chances of securing contracts through Carenodes Opportunity Network and Workforce Mobilization Initiative.

  1. Workforce of the future,
  2. Second acts,
  3. Rural resurgence.
  4. A marketplace of healthcare providers
  5. An ecosystem of healthcare consultants
  6. Clinical executives

Our Workforce Mobilization Initiative calls for increasing opportunities for mid-career workers to get the upskilling they need to continue in their current jobs and have access to new jobs. This Program encourages state governments to improve infrastructure, such as broadband, in rural areas to allow workers to work remotely and remain in their communities if they choose.

TYPES OF OPPORTUNITIES

Non-Schedules Based Contracts

These procurements require a response to an RFP or RFQ. Check back or sign up for new opportunities.

Subcontracting and Other Partnerships

Subcontracting and other partnerships involve working with other contractors in order to implement a master agreement, project segments, joint ventures, and/or other specified engagement frameworks across the United States.

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TRICARE

Effective August 31, 2020

The U.S. Department of Labor’s (DOL’s or Department’s) Office of Federal Contract Compliance Programs (OFCCP) publishes this final rule to amend its regulations pertaining to its authority over TRICARE health care providers. The final rule is intended to increase access to care for uniformed service members and veterans and to provide certainty for health care providers who serve TRICARE beneficiaries. It is also anticipated that this final rule will result in cost savings for TRICARE providers. In a reconsideration of its legal position, the final rule provides that OFCCP lacks authority over Federal health care providers who participate in TRICARE. In the alternative, the final rule establishes a national interest exemption from Executive Order 11246, Section 503 of the Rehabilitation Act of 1973, and the Vietnam Era Veterans’ Readjustment Assistance Act of 1974 for health care providers with agreements to furnish medical services and supplies to individuals participating in TRICARE. Thus, even if OFCCP had authority over Federal health care providers who participate in TRICARE (which this rule clarifies it does not), OFCCP has determined that special circumstances in the national interest justify granting the exemption as it would improve uniformed service members’ and veterans’ access to medical care, more efficiently allocate OFCCP’s limited resources for enforcement activities, and provide greater uniformity, certainty, and notice for health care providers participating in TRICARE. Under the final rule, OFCCP will retain authority over health care providers participating in TRICARE if they hold a separate covered Federal contract or subcontract that is not for providing health care services under TRICARE. TRICARE providers that fall outside of OFCCP’s authority under this final rule remain subject to all other Federal, state, and local laws prohibiting discrimination and providing for equal employment opportunity. This regulation is effective August 31, 2020.

Subcontracted Carenodes Advisory Services (Consulting Agreements)

ADVISORY SERVICES Subcontracted Carenodes Advisory Services (Consulting Agreements)

This agreement (“AGREEMENT”) establishes the terms under which the parties hereto agree that the consultant, who has already provided his or her corporate name (if any) and address (hereinafter, referred to as the “CONSULTANT”) will perform consulting work for a client of CARENODES, Inc. (the “CLIENT”), CARENODES’s offices are located at 3415 S Sepulveda Blvd 10th floor, Los Angeles, CA 90034, (“CARENODES”).  CARENODES and CONSULTANT may be individually referred to herein as a “PARTY” and collectively referred to herein as “PARTIES”.  CLIENT is an intended third-party beneficiary of this AGREEMENT, and CLIENT will be entitled to the rights and benefits enumerated below.

  1. Field of Consultation.  CARENODES wishes to engage CONSULTANT, as an expert in the field provided to CARENODES in the course of the on-line sign-up process, to consult with CLIENT regarding CLIENT’s work in the field(s) also provided in the sign-up process.
  • Term of Consultation.  The period of consultation will be as agreed between CARENODES and CONSULTANT beginning on the first day of the project with the CLIENT, and will continue until the project is complete, as determined by CLIENT in its sole discretion.  Consultation will take place during the term of this Agreement at times and places mutually agreed upon by CONSULTANT and CARENODES.
  • Fee.  CONSULTANT will receive the fees that have been specified separately by CARENODES, and which CONSULTANT agrees constitutes valid consideration for this AGREEMENT.
  • Termination.  CARENODES will have the right to terminate this AGREEMENT upon thirty (30) days written notice to CONSULTANT.
  • IRS Form 1099.  It is understood and acknowledged that the IRS Form 1099 that CONSULTANT will receive from CARENODES will indicate the total dollar amount that CARENODES will have paid CONSULTANT for the calendar year.  It will be CONSULTANT’s responsibility to file a Schedule C to deduct expense reimbursement so that these payments are not taxed.  CONSULTANT understands and acknowledges that this will require CONSULTANT to keep records that designate fee income versus expense reimbursements, including maintaining original receipts.  Note: For those contractors that are incorporated, this provision will not apply.
  • No Conflict.  CARENODES understands that CONSULTANT is available to perform the consulting services as provided herein for CARENODES.  CONSULTANT therefore warrants that this consultation will not cause CONSULTANT to breach any agreement or obligation CONSULTANT may have undertaken with others and that all consulting services to be performed by CONSULTANT under this AGREEMENT are fully consistent with the rules and regulations of his or her employer, if any.  All consulting services to be performed by CONSULTANT for CLIENT will be on CONSULTANT’s own time and without the support or use of the facilities of CONSULTANT’s employer.
  • No Third Party Confidential Information.  It is not CLIENT’s desire to be afforded access to, or to receive any information from CONSULTANT, which is confidential or in any way proprietary to any third party, nor to receive any information the receipt of which implies any obligations of confidentiality upon CLIENT.  CONSULTANT understands that any information provided by CONSULTANT can be freely disclosed and used for any CLIENT purpose including, for example, as incident to activities before the Food & Drug Administration, Federal Trade Commission, and U.S. Patent & Trademark Office.  CONSULTANT warrants that no other party, e.g. any employer, has any right, title or interest to or in any information, ideas, developments and inventions which may be submitted to CLIENT by CONSULTANT in CONSULTANT’s capacity as a consultant to CLIENT.  
  • Obligation of Confidentiality.  During CONSULTANT’s engagement as a consultant, it may be appropriate and necessary for CONSULTANT to have access to certain of CLIENT’s technical and business information and materials.  CONSULTANT agrees to consider as confidential all information disclosed to CONSULTANT and materials given to CONSULTANT by CLIENT during the period of this AGREEMENT, and any technical or business information CONSULTANT may learn, observe, or otherwise obtain concerning CLIENT incident to CONSULTANT’s performance under this AGREEMENT, including the fact that CLIENT may have interest in specific materials or areas of business, all of which is referred to as “INFORMATION”.  CONSULTANT agrees to take all reasonable precautions to prevent disclosure of INFORMATION or materials to third parties and not to use INFORMATION or materials without CLIENT’s express written consent.  These obligations of confidentiality and nonuse will continue beyond the term of this AGREEMENT, but will cease to apply as to any specific portion of CLIENT’s information or material which becomes available to the public. 
  • Term of Obligation of Confidentiality.  These obligations of confidentiality and non-use set forth in the section entitled “Obligation of Confidentiality” and all subsections thereof, will survive the termination of this AGREEMENT and any extensions thereof.
  • Disclosures Incident to On-Site Services.  If consulting is performed by CONSULTANT at a CLIENT facility, the obligations of confidentiality and non-use as set forth in the section entitled “Obligation of Confidentiality” and all subsections thereof, will extend to any and all confidential and proprietary information belonging to CLIENT and acquired by CONSULTANT as incident to performing such onsite services.  This information may include, for example, plant size, crew shifts, number of lines, product shipments, new product development testing, and the like.
  • Publication.  CLIENT will retain the results of CONSULTANT’s consulting work for CLIENT as confidential information.  Therefore, CONSULTANT will not publish or otherwise disclose the results of such work or other information concerning such work, without the express written consent of CLIENT.  In the event that work resulting from CONSULTANT’s consulting is published in the scientific literature, acknowledgement will be made to CONSULTANT in the accepted style, as appropriate.  CARENODES may share information collected from CONSULTANT with CLIENT, business partners, advertising companies, and other third parties.  CONSULTANT will not use CLIENT’s name without CLIENT’s concurrence.
  • Independent Contractor.  CONSULTANT understands and acknowledges that CONSULTANT is an independent contractor and not an employee of CARENODES or CLIENT.  As such CONSULTANT will not be considered an eligible participant in any CARENODES or CLIENT benefit plan other than benefits CONSULTANT was entitled to prior to the execution of this AGREEMENT.  Moreover, CONSULTANT disclaims all other disability programs and unemployment compensation programs in connection with CONSULTANT’s work with CARENODES or CLIENT.  In light of CONSULTANT’s status as a consultant, CONSULTANT understands that it is CONSULTANT’s personal responsibility to report CONSULTANT’s earnings under this AGREEMENT to both the Federal and any appropriate State or Local Governments.  Under some circumstances, however, CARENODES may be required to report payments made to CONSULTANT and/or withhold Income and/or Social Security taxes.  It is further understood and agreed that CONSULTANT is not a partner or joint venturer with CARENODES or CLIENT and has no authority to bind CARENODES or CLIENT to any contract with third parties. 
  • Inventions.  CONSULTANT agrees to disclose promptly and fully to an authorized representative of CLIENT all information, discoveries, works of authorship, designs, software, and inventions, whether or not patentable, conceived or reduced to practice by CONSULTANT as a result of CONSULTANT’s performance under this AGREEMENT (“INVENTIONS”).  All INVENTIONS will be the property of CLIENT.  Accordingly, CONSULTANT will assign outright to CLIENT the entire right, title and interest, both in the United States and abroad, to INVENTIONS, without payment other than that herein provided.  CONSULTANT will execute any documents which CLIENT deems reasonably necessary to secure its proprietary rights as set forth herein, such as to obtain patents, worldwide, or other protection covering INVENTIONS and to fully cooperate as requested to do so in the prosecution of such patents or other applications.  CLIENT will have the above-mentioned documents drafted at its own expense, as will also be the case with any patent or other applications which are filed, and with the prosecution and maintenance thereof.  CONSULTANT warrants that CONSULTANT has appropriate ownership rights in INVENTIONS to carry out CONSULTANT’s obligations under this paragraph.
  • Work for Hire.  Work done by CONSULTANT for CLIENT of a custom design and custom tailored nature will be considered work for hire.  Any materials, such as worksheets, exercises, case studies and videos, created by CONSULTANT for CLIENT as part of such custom design and/or custom tailored work, will be wholly owned by CLIENT, with all copyrights being obtained and retained by CLIENT.  
  • Personally Identifiable Information. CONSULTANT warrants that CONSULTANT will not be collecting or handling any personally identifiable information (“PII”) as a result of CONSULTANT’s consultations performed under this AGREEMENT.  PII means any information relating to a person that is sufficient to cause that person to be identified, directly or indirectly, in particular by reference to an identification number or to one or more factors specific to physical, physiological, mental, economic, cultural, or social identity.  If the scope of consultations under this AGREEMENT changes such that the collecting or handling of PII becomes necessary, CONSULTANT will promptly notify CLIENT in writing regarding such change. 
  • Indemnification.  CONSULTANT will indemnify, hold harmless and defend CLIENT and its AFFILIATES and CLIENTS’s officers, directors, shareholders, employees and agents from and against any and all claims, liabilities, losses, expenses (including, without limitation, fines, forfeitures, reasonable attorney’s fees, disbursements and administrative or court costs), penalties or damages (collectively, the “LIABILITIES”) from any third party claim arising from a breach of CONSULTANT’s privacy representations and warranties provided in the article entitled “Personally Identifiable Information”.
  • Compliance with Applicable Government Laws and Regulations. CONSULTANT will fully comply with all applicable governmental, legal, regulatory and professional requirements, including but not limited to anti-corruption and anti-bribery laws, such as the Foreign Corrupt Practices Act (collectively “LAWS”).   If CONSULTANT has operations physically located in the territorial United States which are involved in CONSULTANT’s performance under this AGREEMENT, then CONSULTANT will fully comply with the employee notice requirements set forth in 29 CFR Part 471, Appendix A to Subpart A and any applicable equal opportunity laws including the provisions in 41 CFR § 60-1.4 (a) (1)-(7), 41 CFR § 60-741.5(a), and 41 CFR § 60-250.5.  CONSULTANT will promptly notify CARENODES and CLIENT if CONSULTANT receives any notice, demand, summons or complaint from any governmental or regulatory authority, agency or other body relating to the subject matter of this AGREEMENT, and will take all steps, at CONSULTANT’s expense, to resolve any issues as promptly as practicable.
  • Anti-Corruption Compliance.  In addition to any other measures necessary to comply with LAWS as described above, CONSULTANT will not, and will ensure that any person or entity acting on its behalf will neither (i) offer to pay, pay, promise to pay, or authorize the payment of money or anything of value nor (ii) give or offer any “facilitating” or “grease” payments (i.e. payments given or offered in order to expedite or secure the performance of a routine government action) whether or not those payments may be considered lawful under the applicable anti-bribery laws to any (a) officer, employee or any person acting in an official capacity for or on behalf of a government or an entity owned or controlled by a government, or of a public international organization; or (b) political party or their officials; (c) candidate for a political office (“PUBLIC OFFICIAL”) in order to influence any act or decision of the PUBLIC OFFICIAL in his or her official capacity or to secure any other improper advantage in order to obtain or retain business or obtain any other business advantage.
  • AFFILIATES.  As used herein, the term “AFFILIATES” refers to any corporation, association, or other entity that directly or indirectly owns, is owned by, or is under common ownership with CLIENT, either currently or during the term of this AGREEMENT.  As used in this definition, the terms “owns”, “owned”, or “ownership” mean the direct or indirect possession of more than fifty percent (50%) of the voting securities, income interest, or a comparable equity in such business entity.
  • Entire Agreement.  This AGREEMENT constitutes the entire understanding between the PARTIES with respect to the subject matter contained herein and supersedes all prior agreements, understandings and arrangements whether oral or written between the PARTIES relating to the subject matter hereof, except as expressly set forth herein.  Nothing in this AGREEMENT may be changed or modified, nor may anything be added to this AGREEMENT, except as may be specifically agreed to in a subsequent writing executed with the same formalities as this AGREEMENT.  For their convenience, the PARTIES may use, from time to time, their standard purchase orders, invoices, or other similar preprinted forms.  The terms of this AGREEMENT shall take precedence over any standard Terms and Conditions language set forth in those forms.
  • Governing Law.  This AGREEMENT will be governed and construed in accordance with the laws of the State of California, United States of America.
  • Headings.  The headings or titles of articles, sections or paragraphs appearing in this AGREEMENT are provided for convenience and are not to be used in construing this AGREEMENT.
  • Notices.  All notices, authorizations, etc. relevant to this AGREEMENT may be personally served or sent by first class mail, postage pre-paid, to the respective PARTIES at the addresses provided and/or via email.
HEALTHCARE SERVICES: Provider / Healthcare Organizations

Carenodes contracts with physicians, facilities and other health care professionals to form our provider networks, which are essential for delivering quality, accessible and cost-effective health care services.

In partnership with providers (medical and non-medical, behavioral, primary, substance abuse, and others), we have developed (and are growing) community-wide coalition efforts geared towards addressing larger systemic health, infrastructure or social determinant issues with a large impact on health.

Click here to learn more about joining Carenodes Network.

Payer Contract Modeling

Contract modeling, or analyzing potential scenarios of reimbursements to understand financial outcomes, provides a proactive approach to financial management by analyzing the impact of different elements such as methodologies, rate changes, pricing, payor mix shifts and ever changing regulations on margins, rather than net revenue alone.

Do it like a Pro: Managed Care Payer Contract Analysis

Contract modeling, or analyzing potential scenarios of reimbursements to understand financial outcomes, provides a proactive approach to financial management by analyzing the impact of different elements such as methodologies, rate changes, pricing, payor mix shifts and ever changing regulations on margins, rather than net revenue alone.

To determine current and future performance, contract modeling can be applied to current contracts and various “what-if” scenarios.

Various Modeling Approaches

1. Medicare break-even computation

A simple way to evaluate the current state of contract performance is to conduct a basic Medicare break-even analysis. This analysis determines the financial impact if payment for all patient populations were according to Medicare rates. A Medicare break-even analysis is a way to benchmark how well commercial payers pay, and a way to evaluate the performance of key service lines, because it takes the payor mix out of the equation and instead uses a consistent reimbursement approach.

2. Assessment of performance of current contracts.

This straightforward analysis determines whether payment is in accordance with the terms of the commercial contract. The analysis will, for example, determine which service lines have the greatest variances between expected and actual payment.

3. Assessment of proposed contracts

This “what-if” analysis determines how changes in the rate and terms of a proposed contract would affect the yield. Changes in clinical services, types of products (i.e., HMO vs. PPO), or even payers can also be modeled. This provides an understanding of, either in actual dollars or percent, whether the proposed contract will result in shortcomings or whether it will improve the bottom line.4.

4. Comparison of traditional and non-traditional reimbursement methodologies.

Value-based payment models represent a new approach for providers. Many of these models put the provider at financial risk for meeting quality/outcomes targets, so understanding the financial implications of such methods before entering into a contract is critical. Likewise, modeling can help determine how implications of potential decreases in Medicaid funding resulting from changes or repeal of the Affordable Care Act, along with increased self pay and bad debt, will affect the bottom line.

5. Assessment of pricing changes.

Contract modeling can be used to better understand the impact of chargemaster pricing changes. For example, if the charge for a procedure increased by 10 percent, the modeling can show how reimbursement would be affected.

Sample Letter: Enlisting Patients Assistance for Claims Payment

Enlisting patient assistance in health insurance claims payment issues.

Date

_____________
_____________
_____________
_____________

RE: Outstanding Health Insurance Payment  

Dear Patient:

I am writing you concerning an issue that has arisen between [ patient’s insurance carrier ] and our office concerning payment for the services provided to you on [ date of service ].”   We have made all reasonable attempts to collect from your insurance company and have not been successful.

PATIENT MESSAGING


[Explain the reason the plan has given for not paying you, or not paying you on time. Stick to the facts. Tell the patient you’re puzzled by the plan’s contention, and that you would appreciate their help in resolving any issues. If the plan’s policy is that the patient is ultimately responsible for the full cost of care, state that.]


We would appreciate your assistance in resolving this matter by:

  • Calling your insurance company directly and asking that the claim in question be paid immediately; and,
  • By asking your employer’s human resources staff to intervene.

Should you or your employer have any questions, please do not hesitate to contact our office at [practice contact and telephone number].

Thank you very much for your assistance and we appreciate your continued business.

Sincerely,

c: [ Name of Insurance Carrier ]

Updates to UnitedHealthcare Cost-Share Waivers

To ensure members are able to access the care they need as the COVID-19 pandemic continues, UnitedHealthcare is expanding cost share waivers for our Medicare Advantage and Individual and Group Market health plans for certain services. Here’s a high-level

The following provides healthcare providers and patients with information surrounding cost-share (copays, etc.) and applicable policies as enacted by United Healthcare (UHC).

Not ALL patients covered by UHC are implicated — please read the line of business (Medicare, type of commercial insurance, etc.) before making potentially detrimental changes in your cost-share collections.

PRIMARY CARE PROVIDERS WITH UHC PATIENTS, NEW POLICIES APPLY TO YOU

To ensure members are able to access the care they need as the COVID-19 pandemic continues, UnitedHealthcare is expanding cost-share waivers for our Medicare Advantage and Individual and Group Market health plans for certain services. Here’s a high-level summary of the changes.

New! Medicare Advantage Primary Care
Care Oct. 1, 2020 through Dec. 31, 2020, UnitedHealthcare is waiving cost share for Medicare

New! Medicare Advantage Primary Care
From Oct. 1, 2020 through Dec. 31, 2020, UnitedHealthcare is waiving cost share for Medicare Advantage plan members for primary care professional services. This applies to in-network and covered out-of-network COVID-19 and non-COVID-19 visits, whether they are conducted in-office or via telehealth.

Telehealth Originating Site Requirements (no changes since 9/28/20)

Telehealth Originating Site Requirements (no changes since 9/28/20)

The updates to originating site requirements that we announced on Sept. 28, 2020 have not changed.

  • Individual and fully insured Group Market health plans:
    • For Individual and fully insured Group Market health plans, there are changes related to COVID-19 and non-COVID-19 telehealth visits, as well as for in- and out-of-network providers. You’ll also find state-specific rules, regulations and emergency periods on the State Provision Exception page. These may vary from federal regulations. If no state-specific exceptions apply, UnitedHealthcare guidelines will apply.
      • COVID-19 and non-COVID-19 in-network telehealth visits: The expansion of telehealth access is extended through Dec. 31, 2020.* This means health care professionals can temporarily provide telehealth services by a live interactive audio-video or audio-only communications system for members at home or another location. For more details on telehealth billing guidance and provider type eligibility, visit UHCprovider.com/covid19.
      • COVID-19 out-of-network telehealth visits: The expansion of telehealth access for out-of-network providers ends Oct. 22, 2020. As of Oct. 23, 2020, out-of-network telehealth services are covered according to the member’s benefit plan and UnitedHealthcare’s telehealth reimbursement policy.*
      • Non-COVID-19 out-of-network telehealth visits: The expansion of telehealth access for out-of-network providers ended July 24, 2020. As of July 25, 2020, out-of-network telehealth services are covered according to the member’s benefit plan and UnitedHealthcare’s telehealth reimbursement policy.

Medicare Advantage:

  • COVID-19 and non-COVID-19 in-network telehealth visits: The expansion of telehealth access is extended through Dec. 31, 2020. Any originating site requirements that apply under Original Medicare are temporarily waived, so that telehealth services provided through live interactive audio-video can be billed for members at home or another location.
  • COVID-19 and non-COVID-19 out-of-network telehealth visits: The expansion of telehealth access is extended through the national public health emergency period, currently scheduled to end Oct. 22, 2020.*
Medicare Advantage COVID-19 Treatment

Cost share waivers (copay, coinsurance and deductible) for COVID-19 testing and testing-related visits are extended through Dec. 31, 2020 for our Medicare Advantage health plans. This applies to in-network and covered out-of-network COVID-19 treatment.

COVID-19 Treatment

Individual and Group Market health plans:

Cost share waivers (copay, coinsurance and deductible) for in-network COVID-19 treatment are extended through Dec. 31, 2020. Out-of-network cost share waivers will end Oct. 22, 2020. Implementation for self-funded customers may vary.

Medicare Advantage:

Cost share waivers (copay, coinsurance and deductible) for COVID-19 treatment are extended through Dec. 31, 2020. This applies to in-network and covered out-of-network COVID-19 treatment.

COVID-19 and non-COVID-19 out-of-network telehealth visits:
  • Individual and fully insured Group Market health plans: For Individual and fully insured Group Market health plans, there are changes related to COVID-19 and non-COVID-19 telehealth visits, as well as for in- and out-of-network providers. You’ll also find state-specific rules, regulations and emergency periods on the State Provision Exception page. These may vary from federal regulations. If no state-specific exceptions apply, UnitedHealthcare guidelines will apply.
  • COVID-19 and non-COVID-19 in-network telehealth visits: The expansion of telehealth access is extended through Dec. 31, 2020.* This means health care professionals can temporarily provide telehealth services by a live interactive audio-video or audio-only communications system for members at home or another location. For more details on telehealth billing guidance and provider type eligibility, visit UHCprovider.com/covid19.
  • COVID-19 out-of-network telehealth visits: The expansion of telehealth access for out-of-network providers ends Oct. 22, 2020. As of Oct. 23, 2020, out-of-network telehealth services are covered according to the member’s benefit plan and UnitedHealthcare’s telehealth reimbursement policy.*
  • Non-COVID-19 out-of-network telehealth visits: The expansion of telehealth access for out-of-network providers ended July 24, 2020. As of July 25, 2020, out-of-network telehealth services are covered according to the member’s benefit plan and UnitedHealthcare’s telehealth reimbursement policy.

Medicare Advantage:

  • COVID-19 and non-COVID-19 in-network telehealth visits: The expansion of telehealth access is extended through Dec. 31, 2020. Any originating site requirements that apply under Original Medicare are temporarily waived, so that telehealth services provided through live interactive audio-video can be billed for members at home or another location.
  • COVID-19 and non-COVID-19 out-of-network telehealth visits: The expansion of telehealth access is extended through the national public health emergency period, currently scheduled to end Oct. 22, 2020.*

Medical Loss Ratio

The medical loss ratio (MLR) is the percentage of premium that health insurers spend on medical care and quality improvement activities. Prior to the Affordable Care Act (ACA), many insurance companies were spending a substantial portion of premium dollars on administrative costs and profits. Since 2011, the federal Department of Health and Human Services has enforced minimum MLR standards. The standards are intended to help consumers by:

  • Providing transparency. Insurance companies must publicly report how premium dollars are spent.
  • Ensuring value for the premium dollar. For insurers in the individual and small group markets, no more than 20% of premium dollars may be spent on overhead; in the large group market, no more than 15% may be spent on administrative costs and profits.
  • Providing rebates. Insurance companies not meeting the MLR standard must provide rebates to their enrollees. The rebate may be provided directly to the enrollee or indirectly through their employer.