This document discusses various factors that impact healthcare costs beyond just insurance discounts. It questions whether larger insurance carriers truly offer the lowest costs given rising expenses and variability in provider charges and quality of claims processing. Independent third party administrators are presented as a potentially better option than large carriers for controlling total spending and improving health, though the document notes not all TPAs are equal in their standards and effectiveness. Overall, the key message is for employers to watch their bottom line costs holistically rather than focus solely on discounts.
An Overview of the ACA (aka Obamacare), October 2013Adrian Ho
Theres a lot of noise out there about Obamacare, much of it politically driven. This presentation is my attempt to focus on the facts and boil down the over 2000 page law into a short succinct summary
The Affordable Care Act changes everything for payers as they will have to move from a B2B strategy to a B2C strategy to manage care and wellness. That will require redesigning member access and engagement so that it is omnichannel, interactive, and that employs design-thinking.
Government data shows rising OOP spending for consumers, but excludes some types of health-related items and services that can add significantly to the total amount and consumer share of spending. This infographic exposes these “hidden costs” that account for almost one-fifth of total health care spending.
For more information, visit
Case Study: Re-Engineering the Operational Foundation to Fund the Future of Q...Mischa Dick
Success Snapshot:
* $21M cash gains achieved within the first year of engagement.
* 200+ employee CBO redesign for scalable growth
* Employee engagement scores at record high levels
An Overview of the ACA (aka Obamacare), October 2013Adrian Ho
Theres a lot of noise out there about Obamacare, much of it politically driven. This presentation is my attempt to focus on the facts and boil down the over 2000 page law into a short succinct summary
The Affordable Care Act changes everything for payers as they will have to move from a B2B strategy to a B2C strategy to manage care and wellness. That will require redesigning member access and engagement so that it is omnichannel, interactive, and that employs design-thinking.
Government data shows rising OOP spending for consumers, but excludes some types of health-related items and services that can add significantly to the total amount and consumer share of spending. This infographic exposes these “hidden costs” that account for almost one-fifth of total health care spending.
For more information, visit
Case Study: Re-Engineering the Operational Foundation to Fund the Future of Q...Mischa Dick
Success Snapshot:
* $21M cash gains achieved within the first year of engagement.
* 200+ employee CBO redesign for scalable growth
* Employee engagement scores at record high levels
Payer-Provider Summit Boston 2014 - Presentation "Payer-Provider Partnership Models for Health Care Innovation" with Tom Olenzak, Director, Independence Blue Cross
Healthcare Reform 2011: The Good, the bad and the ugly (Part 2)David Goldstein
Interpreting these new laws and regulations are complex but their affect on insurers, employers, medical professionals, and patients is even more confusing. Join HOW for a unique look at these changes and their influence on healthcare decisions for the coming years.
These are the slides displayed during the September 28th webinar on Understanding the Importance of ACOs presented by ROI2 and hosted by Dr. Barry Mennen, MD. With Matt Eyles and Jim Smith.
As public and private insurers move away from traditional fee-for-service payments, healthcare organizations are struggling to make the leap. Market share, regional characteristics, financial health and an organization’s mission and culture are shaping the path as the flow of money shifts and the skills to manage and measure risk are being redirected in largely untested ways.
Earlier this year, my company had asked me to present Value-Based Care at our all employee meeting. I created this Jeopardy like template in powerpoint with sound, hyperlinks. Don’t try to create yourself, let me save you lots of time, just message me cjfulton259@hotmail.com and I'll send it over. Great tool for engaging healthcare audience or training.
20091207 Elements to Consider for Alternative Treatment Centersguestcf34e2
This workshop was presented at the World HealthCare Congress Leadership Summit in Dallas on 12/7/09. John Corpus established the content of the workshop; Ken Berndt and Bruce Shepard presented the content of the PPT. John, Ken, and Bruce contributed to the structure and content of the PPT.
diagnosis code confusion leads to medical billing errorsMichel Desuza
While outsourcing your medical billing services in California, ensure your billing partner is equipped with the latest demands of medical billing and coding according to the healthcare reforms.
Evolution from Health Insurance to Health Solution_GuideWell
CEO and Chairman, Pat Geraghty, shared how GuideWell is driving value in health care through collaboration with strategic partners; designing innovative products and member engagement platforms, and advancing care delivery all intended to support the Triple Aim. Pat presented this deck at the NIHCM Congressional briefing on November 6, 2015.
A step-by-step methodology to evaluate a department's revenue stream. Identifiy and assess mission-critical revenue trends to prompt remedies and compromises that maintain the revenue stream.
When it comes to health insurance, understanding your options may seem a little daunting. We have put together this presentation to help you understand your options. The first step to choosing the right health insurance for you and your family is understanding your options.
Explore how the Affordable Care Act and creation of state level and national exchanges has impacted member risk profiles and demand for small-group and individual health plans.
A consumer study prepared by PwC to investigate how behavioral, regulatory, and technological disruption are changing consumer's approaches to managing their health.
Studying in Queensland: Uncovering Motivations & Experiences of International...Lara Klestov
As a part of the work integrated learning program at the University of Queensland (UQ), The Department of Tourism, Major Events, Small Business and the Commonwealth Games (DTESB) engaged the University of Queensland to undertake a research study investigating the motivations and experiences of international students in Queensland. This presentation highlights the results from 100 face-to-face surveys that were conducted.
EVALUATION OF A NEW INCREMENTAL CLASSIFICATION TREE ALGORITHM FOR MINING HIGH...mlaij
Abstract—A new model for online machine learning process of high speed data stream is proposed, to
minimize the severe restrictions associated with the existing computer learning algorithms. Most of the
existing models have three principle steps. In the first step, the system would create a model incrementally.
In the second step the time taken by the examples to complete a prescribed procedure with their arrival
speed is computed. In the third and final step of the model the size of memory required for computation is
predicted in advance. To overcome these restrictions we proposed this new data stream classification
algorithm, where the data can be partitioned into stream of trees. In this algorithm, the new data set can be
updated with the existing tree. This algorithm, called incremental classification tree algorithm, is proved to
be an excellent solution for processing larger data streams. In this paper, we present the experimental
results of our new algorithm and prove that our method would eradicate the problems of the existing
method.
Payer-Provider Summit Boston 2014 - Presentation "Payer-Provider Partnership Models for Health Care Innovation" with Tom Olenzak, Director, Independence Blue Cross
Healthcare Reform 2011: The Good, the bad and the ugly (Part 2)David Goldstein
Interpreting these new laws and regulations are complex but their affect on insurers, employers, medical professionals, and patients is even more confusing. Join HOW for a unique look at these changes and their influence on healthcare decisions for the coming years.
These are the slides displayed during the September 28th webinar on Understanding the Importance of ACOs presented by ROI2 and hosted by Dr. Barry Mennen, MD. With Matt Eyles and Jim Smith.
As public and private insurers move away from traditional fee-for-service payments, healthcare organizations are struggling to make the leap. Market share, regional characteristics, financial health and an organization’s mission and culture are shaping the path as the flow of money shifts and the skills to manage and measure risk are being redirected in largely untested ways.
Earlier this year, my company had asked me to present Value-Based Care at our all employee meeting. I created this Jeopardy like template in powerpoint with sound, hyperlinks. Don’t try to create yourself, let me save you lots of time, just message me cjfulton259@hotmail.com and I'll send it over. Great tool for engaging healthcare audience or training.
20091207 Elements to Consider for Alternative Treatment Centersguestcf34e2
This workshop was presented at the World HealthCare Congress Leadership Summit in Dallas on 12/7/09. John Corpus established the content of the workshop; Ken Berndt and Bruce Shepard presented the content of the PPT. John, Ken, and Bruce contributed to the structure and content of the PPT.
diagnosis code confusion leads to medical billing errorsMichel Desuza
While outsourcing your medical billing services in California, ensure your billing partner is equipped with the latest demands of medical billing and coding according to the healthcare reforms.
Evolution from Health Insurance to Health Solution_GuideWell
CEO and Chairman, Pat Geraghty, shared how GuideWell is driving value in health care through collaboration with strategic partners; designing innovative products and member engagement platforms, and advancing care delivery all intended to support the Triple Aim. Pat presented this deck at the NIHCM Congressional briefing on November 6, 2015.
A step-by-step methodology to evaluate a department's revenue stream. Identifiy and assess mission-critical revenue trends to prompt remedies and compromises that maintain the revenue stream.
When it comes to health insurance, understanding your options may seem a little daunting. We have put together this presentation to help you understand your options. The first step to choosing the right health insurance for you and your family is understanding your options.
Explore how the Affordable Care Act and creation of state level and national exchanges has impacted member risk profiles and demand for small-group and individual health plans.
A consumer study prepared by PwC to investigate how behavioral, regulatory, and technological disruption are changing consumer's approaches to managing their health.
Studying in Queensland: Uncovering Motivations & Experiences of International...Lara Klestov
As a part of the work integrated learning program at the University of Queensland (UQ), The Department of Tourism, Major Events, Small Business and the Commonwealth Games (DTESB) engaged the University of Queensland to undertake a research study investigating the motivations and experiences of international students in Queensland. This presentation highlights the results from 100 face-to-face surveys that were conducted.
EVALUATION OF A NEW INCREMENTAL CLASSIFICATION TREE ALGORITHM FOR MINING HIGH...mlaij
Abstract—A new model for online machine learning process of high speed data stream is proposed, to
minimize the severe restrictions associated with the existing computer learning algorithms. Most of the
existing models have three principle steps. In the first step, the system would create a model incrementally.
In the second step the time taken by the examples to complete a prescribed procedure with their arrival
speed is computed. In the third and final step of the model the size of memory required for computation is
predicted in advance. To overcome these restrictions we proposed this new data stream classification
algorithm, where the data can be partitioned into stream of trees. In this algorithm, the new data set can be
updated with the existing tree. This algorithm, called incremental classification tree algorithm, is proved to
be an excellent solution for processing larger data streams. In this paper, we present the experimental
results of our new algorithm and prove that our method would eradicate the problems of the existing
method.
1 aedl - iywinc lite block presentation march 2015 engMichael Walsh
New Patented Super LED Hi/Low-Bay LED Lights.
130 lm P/W, Life 150,000+ hr. life.
Operating temperature: -45 Deg C to +50 Deg C.
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On Thursday July 19th, 2012, the Taylor-Wilks Group held a free Health Care Symposium to provide resources and answer questions regarding the Affordable Care Act. This is some content from the event.
Guidelines for the Colorado Health Benefit Exchange and our Federal Exchange are still up in the air. What do these various funding, administration, and oversight issues mean for employers and how will plan pricing, availability, and benefits be addressed? This presentation is designed for the Colorado business leader who needs to understand the current state of the exchanges. In this session, we’ll go over the very latest developments and how they could impact local businesses, discuss how you can create a proactive multi-year benefits strategy, and introduce resources to help you stay on top of this constantly changing landscape.
5 Mistakes Hospitals Make with Call Coverage AgreementsMD Ranger, Inc.
This deck covers 5 critical mistakes that hospitals make with call coverage agreements and how to avoid them going forward.
We will cover:
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- Determining commercial reasonableness
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Compliance and Legal Risks in Laborist, Surgicalist, and Hospitalist Arrangem...MD Ranger, Inc.
Have you structured your hospital-based physician contracts to address all aspects of compliance?
Hospitalist agreements involve unique compliance and financial issues, particularly when global payments and advanced practice providers are involved. Risks include indirect compensation, billing and other compliance issues. This presentation will discuss compliance risks and provide guidance on how to structure compliant contracts and business arrangements.
Your Bottom Line: What the Affordable Care Act Means For Your Nebraska Small ...Small Business Majority
Hosted by the United States Department of Health and Human Services and Small Business Majority. This webinar focused on what the new healthcare law, the Affordable Care Act, means for Nebraska small businesses. It focused on both federal and state provisions to help local small business owners understand how the law will affect them.
MGSI provides healthcare eligibility verification services to streamline your medical claim processes at affordable prices. Choose us as your billing partner!
Akash Desai of the Philadelphia Department of Public Health (PDPH) presented on health insurance premium/cost-sharing assistance at the December 2016 meeting of the Ryan White Planning Council.
Workers compensation is one of the largest expenses that many businesses face. Many employers will be shocked to learn how the system actually works. This guide is written in simple terms and focused on highlighting the important facets of this often misunderstood system.
The Affordable Care Act: What Independent Consultants Need to KnowMBO Partners
Gene Zaino and Dave Putt, both experts on the independent workforce, provide essential information on the ACA basics with a special focus on the independent worker.
Find more resources for independent professionals at www2.mbopartners.com/ic-resources
This white paper explores how the health care reform bill will affect Medicare Advantage, Part D and Medicare Supplement plans, and how savvy agents can capitalize on the opportunities that will inevitably arise from this change.
Similar to Bigger discounts reduce healthcare costs (20)
3. Some Questions…
• If carrier discounts are so significant, why are costs
accelerating so rapidly?
• If big discounts from ABC insurance equal the lowest
healthcare costs, why aren’t all companies with
them?
• Follow up question: How can those companies that
are self insured with an independent TPA be getting
better results if not with the ABC Insurance company?
4. Answer: It’ s Always What You Spend,
Not What You Save
• Discounts are important, BUT they are not the only factor to control claims
costs.
• Large carriers administration systems are not necessarily the most efficient
claims processing due to the large volume they are forced to handle.
• In 2008, the American Medical Association agreed on a settlement with
the Blues parties to limit overpayment collections to no later than 18
months after the claim was paid.
• Food for thought: If the Blues were paying claims accurately in all cases,
why do they need to go and get their money back from the providers?
Why later than the current plan year? Who gets the money if recoveries
are made?
“Ge1ing out of the hospital is a lot like resigning from a book club.
You'ʹre not out of it until the computer says you'ʹre out of it.”
Erma Bombeck
5. Billed Charges
The Moving Target
• The current system for hospitals and doctors geLing paid for
services is primarily done on billed charge process
• Total billed charges can fluctuate significantly between providers
• If the billed charges are higher, even with a bigger discount, your
net payments will be higher.
• Independent networks are designed to create steerage to the
more cost effective, local providers that controls the total expense
to the group.
6. The Legend of a Wellness Visit
• Robert lives and works in San Diego, CA and his son needs a wellness visit and
immunizations.
• His health plan a large carrier network with a blue logo and he has a wide
geographical selection of providers that he can seek for his son.
• At the same premium rate, Robert can go to any facility. He chooses one and
takes his son for his physical.
• Result:
o Provider chosen charges $900 for the lab work alone.
o Smaller provider within network charges less than $300.
o The out of pocket expense to Robert is the same so he feels no
financial impact of his decision because wellness is paid at 100%.
o The employer that provides his insurance just got tagged for an
additional $600 to their plan costs.
o Multiply $600 times the number of children on your health plan.
o Is the large network surgical center worth $600 more per child than a
smaller network facility just to draw blood? Who makes that
decision? How many claims work that way? That is the question to
ponder…
True case study. Names changed to protect the innocent.
Claim data 2011.
7. The “Hidden” Rx Increase
• Large carriers are usually partnered up with giant Pharmacy Benefit Managers
who handle the financial seLlement of their RX component
• PBM’s have become bloated companies focused on delivering increased
revenue to their shareholders not aggressively reducing RX costs
• Rx is rapidly becoming a larger component of the total medical spend. The
development of expensive specialty injectable drugs will continue this paLern.
• The US industry’s net income skyrocketed from about US $400 million in
2008 to a record US $3.7 billion in 2009. *
• PBM’s can differ in ingredient costs for the same RX by 10 to 15 percent
• PBM’s can steer, via copays, patients to use higher rebate medications that
provide bigger revenue to the PBM, but increased costs to your business
* Beyond borders: global biotechnology report 2010, Ernst & Young’s 24th annual report on the
biotech industry.
8. Claims Payors Are Different
• Third Party Administrators, whether you are self funded or
are fully insured, are different.
o Different software
o Different procedures
o Different administration
o Different overhead structures
o Different audit protocols
o Different mindset
o Different volume processing load
Bigger is not better when it comes to claims processing.
More auto adjudication (Explains the large recovery efforts)
More pressure to get claims paid faster
Less Utilization Review of each claim
Less chance for disease management intervention
Less chance of subrogation coordination
9. Why Bigger Is Not BeLer In Paying
Claims
• Large claim processors need to move claims through an
electronic system very quickly
• Payments can be erroneously made for:
o Non-eligible items per the Plan Documents
o Deductibles can be misapplied.
o If deductibles need to be corrected, all plan claims would need to be review for
accuracy. Most large systems cannot accommodate this level of adjustment
o Payment for duplicate services
o Payment for similar treatments billed under different codes
o Payments that exceed maximum plan benefit payouts
o Payments for treatments not authorized by the plan holder
o Claims should have been covered by another provider
o Ineligible dependent claims
• This is why the large payers need to go after overpayments after
the fact.
• Fully insured clients will not see the recovery of funds reduce their
direct premium costs.
11. Independent Third Party Administrators
• Technology has allowed many companies to pay
medical and RX claims for clients
• Not all software systems are using current developer
standards and are stuck 20 years behind the times
• Mindset of the TPA owners could be different
o Some are more aggressively managing and auditing claims on the fly
o Letting software simply pay the claims doesn’t address the issue of the
appropriateness of paying a claim
o Could be no different that hiring a large claim payer
• Not all TPA’s have similar PPO network connections
• Customer service standards can be radically different
12. BoLom Line…
• Watch YOUR bottom line!
• Acknowledge the importance of discounts, but don’t
determine the fate of your health plan solely on that
factor
• Many companies focus on hospital discounts and are
getting whacked on higher RX costs due to large carrier
PBM contracts and on physician costs where most of the
claims occur.
• Focus on cost avoidance, not just cost discounting
• Introduce Risk Reduction/Health Improvement Strategies