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Healthcare update 2

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Based on misconceptions regarding the exchanges and healthcare reform I created a presentation that covers some of the basic issues and actions to consider.

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Healthcare update 2

  1. 1. Healthcare Update challenges and opportunities Taino Consultants Inc. Dr. Jose I. Delgado
  2. 2. Main Topics • Affordable Care Act – Exchanges • Insurance Products and Patient Responsibility • Action Items for CY 2013
  3. 3. Exchanges • What are the exchanges • Products • What does it means to you
  4. 4. What are the Exchanges? • Online shopping marketplace (i.e. Amazon) • Type of Exchanges – – – – State Federal Hybrid Commercial
  5. 5. Products • Plans defined by Insurance Companies – Healthcare Professionals and Organizations may not be participating in all Plans/Products – Plans have controls on who they want to participate – Closed Networks • Patients Shopping based on price – Lower Monthly = higher out of pocket – Lower monthly = restricitve Networks
  6. 6. Companies and average changes (FL)
  7. 7. Local Plans Individual Family Monthly Cost $500 - $700 $1,200 - $1,600 Co-pay Primary $50 - $100 $50 - $100 Co-pay Specialist $50 - $100 $50 - $100 $6,000 $8,000 Deductible
  8. 8. Higher co-pays and deductibles means • Patients increased financial responsibility – Most of the money will be collected from the patient – More cash, checks, credit cards transaction in the office – Best and most efficient method to collect is at the office – More questions from patients as they may not understand their costs and coverage – Potential higher costs for billing Companies
  9. 9. Risks of cash • Re-education of patients • Difficulty on receiving payment from individuals • Theft • Costs
  10. 10. Other Issues to consider • In/out of Network – Smaller Network easier to manage • Allowables – Fee schedule – Contract fees (beware of “based on …….”) • Cost of doing business – Overhead rate? – Cost of your services? • Cost of sending invoice?
  11. 11. Risk and Reimbursement • Affordable Care Act provides consumers with 90 days to go without paying their premiums and not lose coverage – Insurers don’t have to process claims – Providers must continue to offer services without payment • Lower Reimbursement from Exchange Products – For example: BC/BS of Illinois premiums are 20-30% lower – Increased volume doesn’t equal increase reimbursement
  12. 12. What does it means to you • Business Operations changes – Cash fail safe operations – Cost increases? • Relationships (Peers, Networks) – Return on investment? • Marketing – Pick you clients/take control – Be Proactive It is not business as usual!
  13. 13. ACA Compliance more than Insurances • OIG compliance plan required – Conduct audit – Develop Policies and Procedures • OIG Sanction list http://oig.hhs.gov/exclusions/ – Train staff – Document actions
  14. 14. Meaningful Use beyond EHR • Audits – Random and conducted by CPA firm – Documentation needed – Failure one item requires return of incentive • Interaction with other laws – False Claims Act (30 day window to return money from discovery) • Action Items – Risk Analysis – Documentation
  15. 15. HIPAA Security – Omnibus Rule • Business Associate Contracts – Obtain assurances • • • • Risk Analysis Risk Management (policies and procedures) Breach Response & Breach Notification Training
  16. 16. Summary • Significant changes that will affect all aspect s of the Healthcare Business • Healthcare and Professionals must take control to survive – Consider key aspects: • • • • Return on Investment Income Generating Activities Marketing and selecting right patient mix Risk and required actions
  17. 17. Dr. Jose I Delgado 904-794-7830 DrDelgado@Tainoconsultants.com www.tainoconsultants.com

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