Health and Government Operations Committee: November 17, 2020

Guests:
Robert R. Neall, Health Secretary
Chad Burholder, Chief Operating Officer, Optum Behavioral Health
Dennis R. Schrader, MDH Chief Operating Officer and Medicaid Director
Dr. Aliya Jones, Deputy Secretary of Behavioral Health

Optum Transition Update 

The Maryland Dept. of Health transitioned from a grants-based behavioral health financing model to a fee-for-service financing model for the approx. 2,200 registered providers in 2017-18.  The Optum transition started Jan. 1, 2020.

Secretary Neall: Our goal has been to ensure that 200,000 Maryland Medicaid beneficiaries receive clinically appropriate needed behavioral health services and access to robust quality of care; provider payment system operational performance; providers are reimbursed for authorized services provided’ and that over and under-payments to providers made during 1st half of 2020 estimated payments are reconciled by the end of the fiscal year.  

Three reasons for the transition:

1. Financial accountability
2. Quality health care measure tracking
3. Leveraging Medicaid

Optum had a less than successful launch in Jan 2020 as a result of the previous vendor, Beacons, data failure.  Optum was told to begin estimated payments in January, through the beginning of August based upon the provider’s historical average payments in 2019.  MD paid out slightly over $1B in eight (8) months to about 2,200 behavioral health providers. This had an unplanned benefit of providing a stable cashflow during most of the restrictive months of the spring COVID shutdown to providers. However, providers have been asked to submit claims for actual services provided during this time.

Since August 13, 2020, Optum has processed and paid out $453M, or about $32M a week (this is pretty much in line with historical trends). We have daily progress reports since January.  

Chad Burkholder:

• Optum is frustrated and very disappointed with how this implementation has gone 
• The claims performance has improved exponentially since the relaunch in July and August 2020
• Authorization performance – the process by which Marylanders gain access to care
• Service performance experienced by providers and participants has been below our standards.  We are taking urgent steps to address that performance. 

The $453M has been paid and we are actively monitoring that to ensure that we understand where additional challenges may be experienced and what needs to be addressed to continue to make sure that that amount reflects what has been serviced. 

The turnaround time has been improved and majority of claims are processed within 14 days. 

Top 5 Claim Denial Reasons (currently at about 14%; improved from 26%):

1. Authorization is not on file
2. Invalid Level of Care, Modifier, or Place of Service billed
3. Claim billed under incorrect provider type
4. Participant eligibility not effective
5. Service Payable by other Primary Carrier

Optum is processing authorizations at a rate of 97.8%.  These are authorizations that have been successfully submitted and processed through the system.  

Customer Service Experience: We fully recognize that service for the providers has been absolutely unacceptable.  To be frank, and open and honest, Optum underestimated the complexity of the service model that was needed for service providers in Maryland.  We leveraged an external vendor to support the customer service function and that was a mistake. We have taken recent steps to correct that – we have severed our relationship with our external vendor and bringing all service related functions inside Optum’s enterprise.  This is going to drive more direct accountability within my team and more direct control. The transition should be complete by the end of February.  

We also realigned accountability for managing the service functions, and specifically the vendor performance over the past six (6) weeks.  

Optum is committed to getting us right.  

Dennis Schrader:

1. We paid out about $1B in estimated payments and about $163M will come back to the state through the reconciliation process. This is a requirement of the Federal gov’t in order to receive matching funds. 

Timeline for Assisted Reconciliation

November: Release all remaining key reconciliation documents. 

December through May 2021: MDH and Optum work closely with providers to reconcile payments. We will waive the necessary timeline for ninety (90) days appeals for dates of service prior to August 3rd and the sixty (60) days reconsideration period for six (6) months.  

June 2021: Collaborate with providers to develop a recoupment process.

There will be no recoupment until we have completed this process.  We have already sent out an alert to all the providers announcing this assisted reconciliation, and in addition to that we have offered to have dedicated reconciliation managers who will work with the providers. So far about over a thousand providers have responded with requests to engage in that process. There have been, to date, about 207 assisted reconciliation meetings.  

Dr. Aliya Jones:

Our provider outreach includes:

• Meetings hosted by Optums provider relations of which there have been 184
• Webex training sessions of which there have been 47 instructor led sessions that have been attended by over 2,600 provider staff
• Monthly provider council meetings of which there have been 4
• Weekly operations improvement committee meeting of which there have been 14

Q&A:

Del. Kelly: The contract with Optum allows us to levy daily fines if their obligations aren’t being fulfilled.  Have we considered penalties for Optum not fulfilling their contact?

Schrader: There are two parts to that. We have in the developmental budget (which is the first costs) $8.8M and we are holding back $4.8M until we get to the end of this and determine how that plays out.  Secondly, we have taken this approach with Optum because of some of the things that Mr. Burkholder mentioned.  Unfortunately Beacon had virtually no documentation for years on how this system worked. What we are doing now through this process is developing a process.  So our approach has been to partner with Optum so that the state is going to benefit from this system. 

Del. Henson: It is my understanding that these issues are not being experienced by those who hold private insurance; strictly an issue for those on Medicaid… are we seeing providers who are not willing to work with Medicaid patients or have we seen any providers who  have opted out of the system all together and no longer move forward?  

Dr. Aliya Jones: We don’t have any numbers on that and it is a concern.  We have heard anecdotally people saying that, but there’s no data to substantiate that.  The Behavioral Health Administration is about to do another survey of providers around their financial challenges at this time, and one of the questions we are going to be asking is to try to determine if providers are making different decisions with regards to taking or no longer taking Medicaid patients at this time. So we should have some data for you about that in a month or so.

Del. Young: What process do you use to independently investigate the customer service record of a potential provider, and going forward do you have a very specific recommendations as to how you can work in partnership with the General Assembly to ensure ongoing transparency and accountability? 

[Further clarification requested]

Young: Initially using a process to select or investigate a provider, for example checking with other entities that receive their services, conducting services for customer service complaints, searching for relevant lawsuits. 

Schrader: The way the Maryland system works; we are one of the few states in the nation that has a fee for service. In effect, the state has the responsibility for the provider list.  We have gone to any willing provider, and one of the things that Dr. Jones and I have talked about is the quality that the providers are rendering to us, and how do we begin to shape the vendor pool based on those kind of factors.  It has not been done in the past but next year we are going to start back down that road.

Dr. Jones: For all of our license providers, most of our provider types, we do have an auditing process and patients can render any complaints they might have. It is not paneled like what we see with a private insurance company.  

Vice Chair: I heard that Secretary Neall stated that since January 1st, there have been trainings and meetings, but no testing environments or access to the system prior to January 1st. Can you tell us why that is and also what is the plan to address the loss damages related to lack of payment, staff turnover, liability issues, fees people incurred, line of credits that people had to ask for? Are you planning to use some of that money that Mr. Schrader referenced? 

Sec. Neall: I will take that list and respond individually to each one we did not come prepared for that level of detail unfortunately I’d like a written list because I don’t think I caught it all and once we get the list we will respond.

Vice Chair: why was there no test environment, or access to the system prior to January 1st? 

Sec. Neall: Frankly, I don’t know the answer to that question. 

Burkholder: I would acknowledge Madam Vice Chair that the test environment was far too late up against the implementation date. We had an extraordinarily brief time period in which to launch the new program.  The contracts were finalized in late August and September, and that left us about two months.  As we commented previously, the documentation that was available to support the implementation was very limited, and we found ourselves having to develop the processes at the time of also establishing a tool in the system.  That was not anticipated and that created a delay.  We ended up doing a lot of testing in December and the January time frame.  We have had a robust engagement with the providers during that time to assist us with testing of new capability.  We are thankful for the many providers who have continued to assist us with that. We have a most improved process today compared to what it was in Dec. Jan and February.

Vice Chair: What is the plan to address the loss damages created from lack of payment to these businesses? Is some of that money [Sec. Schrader referenced] perhaps going to be used to assist some of these businesses that have suffered as a result of these lack of payment?   

Schrader: That is largely a legal matter, and I’m sure that we are going to look into that. But I’m not so sure that is something that I should speculate on in a public hearing.

Del. Rosenberg: Is there any need for any recourse against Beacon? If so, is that adequately handled in the contract or existing law?

Sec. Neall: It is a legal question. 

Del. Reznik: If Optum was so woefully unprepared to meet the challenges of the system, how willfully inadequate was the Optum proposal that it was so unprepared to be able to take over and provide these benefits to these folks?

Schrader: During the bid process, we asked that same question because there was a gap.  The original contractor was being paid $20M a year. The new bid was $27M a year.  The incumbent’s bid was $37M a year.  They submitted a proposal that was nearly double what they received in the last year of their contract.  We could not justify that.  Optum had the highest technical score by the evaluation committee.  When you look at the numbers, it wasn’t that they underbid, it was that the incumbent way overbid it.  

Del. Smith: At what point can you ask for the subcontractor be replaced? 

Burkholder: The state has some very unique and specific requirements which made the use of the Cato tool appropriate and necessary. The state of Maryland has some different compliance oriented regulations that frankly many of our Medicaid partnership states do not have…  The vendor that we are replacing is the call center vendor.  Our focus is to get the tool working right now.  

Chairman: Do you have a timeline for when the tool will be working?

Burkholder: Right now we think that the tool is performing significantly better than it was previous. We think we’re actually not that far off the mark today, however, there are significant and specific challenges that the specific providers groups or provider services that have been problematic for specific providers. We think there will be material progress in the first quarter.  

Del. Lewis: My question is for Mr. Burkholder. You mentioned that there was a pattern of difficulties certain providers are experiencing greater difficulties with your software system than others. You said specific providers/specific services that makes me curious whether there is a pattern or trend and obstacles to getting care for certain populations. I wonder if you could be more specific about that. 

Burkholder: What I’m specifically referring to are examples where claims may be paid, for example, a day short and need to be reprocessed because of these specific service type or specific provider type where their configuration was much more difficult or frankly not as well understood. I think that is wholly connected to the comments that secretary Schrader made relative to the need for improved documentation so some of the items that we are wrestling with right now are items that were not clearly understood at the time of the layout of the requirements; they are becoming better understood. Unfortunately some providers have experienced challenges and we are working actively to address those. As far as individuals not receiving care, I think I would have to yield to my colleagues for additional comments. I will say that the data does not indicate that in the least, and we have been successful in assuring authorization and we’re working hard to manually assure support of payment of those services.

Dr. Jones: I would agree in that we, at the Behavioral Health Administration, are not aware of any patients that have not been able to receive care that we have not been able to address very immediately, but in general, I cannot say that I hear very many reports about people not being able to get care because of this issue.

Chairman: Neall, was it a technical advisory or assessment committee that you used in making the decision on this bid.  Were there only two bids for this contract? Could you describe the technical people who you used to consult?

Sec. Neall: I cannot recall or recite who it was.  I will be happy to get you their information. I’m almost sure that we had only two qualifying bids.  There may have been other bidders that eliminated some components, I cannot recall who they were, but we ended up with two qualifying bidders.  I will add that to the response that we will get to you.

PROVIDERS

Lori Doyle, Public Policy Director of Community Behavioral Health Association of Maryland (CBH)
Lauren Grimes, Assistant Director of CBH

About CBH:

Our members’ services

• 85 members provide services at over 848 licensed sites
• Average member:
  • $9M dollar business
  • In operation for 44 years
  • Been through four($) ASO Transitions
  • Licensed for three (3) different program types, although one-third licensed for 5+ program types.

Lori: This is our 4th ASO and you’ve never heard a peep out of us before because by and large, these transitions have gone very smoothly. We always expect bumps in the road, but nothing like this. It would be really hard to overstate the disruption that this transition has brought to us.  At this point, we are frustrated and exhausted, at a time that we really need to turn our full attention to the impacts of COVID on both our clients and our staff.   

Members’ license programs

• Residential Services including:
  • Residential treatment centers (RTCs)
  • Respite care
  • Residential crisis services
  • Residential rehabilitation programs
  • Supported housing
• Outpatient substance-related services
  • DUI education programs
  • Level 1 outpatient treatment programs
  • Level 2.1 intensive outpatient treatment programs
  • Level 2.5 partial hospitalization programs
  • Gambling program
  • Opioid treatment services
  • Withdrawal management services
• Outpatient mental health services:
  • Outpatient mental health clinics
  • Group practices
• Specialty mental health services:
  • Mobile treatment or Assertive Community Treatment (ACT) 
  • Capitation program
  • Therapeutic behavior services (TBS) 
  • Targeted case management (TCM)
  • 1915(i) services
  • Psychiatric rehabilitation programs (PRP)
  • Psychiatric day treatment programs
  • Supported employment programs

Our services are reimbursed in different ways: some are fee per service basis, some things are reimbursed on a monthly encounter basis and you have to submit a minimum number of encounters to submit a bill, and some things are paid on a per diem basis.  And this has no doubt contributed to the problems that Optum has experienced. But again, in the past, our ASO vendors have been able to grapple with this and do it efficiently and well.

Missing reports and broken promises:

Claims processing is the exchange of large amounts of data between providers and payers, defined by national conventions and industry standards.  Only one of the ASO vendor’s four (4) standardized data exchange reports is functional. 

One of the biggest issues that we have with the CATO system is the lack of accurate reports. Without these, providers cannot do revenue cycle management. When we get these reports, they are erroneous, or only some providers get them.  There’s still not a standard operating procedure. Without these things we can’t track what has been paid, what has been denied and why, do we need to resubmit? So all of these things need to be worked out before we can even begin to do reconciliation.   

Optum’s response has been that since the technology can’t do the job, is to institute manual fixes… leads to human error… lags in payment.

Standard payer functions Optum cannot currently perform correctly

• Send payments and patient information to treating provider only
• Apply eligibility decisions retroactively
• Process claims with the correct insurance type
• Assign encounters to case rate claims
• Pay claims with different rates for different provider types
• Process 100% of clean claims within 14 days
• Notify providers within 5 days of claim lacking sufficient info to process

**26% claims processing standards in ASO RFP that Optum does not appear to perform as expected. **

We need three things in order to do reconciliation: 1) technology, 2) the right tools and 3) we need time.  Our providers are saying it will take a year to get through all of that. 

1. Technology that works:
   1. Accurate batch rejection reports (999 reports);
   2. Reports so providers can resubmit batches (277CA reports); 
   3. Accurate and complete claims history in a format that can be electronically posted (835s);
   4. Denial codes applied accurately and consistently (835 denial codes);
   5. Search capability within Incedo that returns accurate results within search parameters;
   6. Ability to process encounters and assign to case rates.
2. Tools that work:
   1. List of systemic issues that delineates claims to be resubmitted by providers or Optum.
   2. Sufficient and adequately trained customer service representatives who can provide accurate and timely responses.
3. Time

We have been meeting with Optum staff regularly.

Ann Ciekot, Public Policy Partner and representing the Maryland Assoc. for the Treatment of Opioid Dependence and the Maryland Addictions Council:

Every type of provider has had and continues to have problems with this new ASO.  No one wanted estimated payments; it was something the state was really forced to do.  We have no faith that it is possible to fix this inflexible system… we do not have faith in the accuracy of the department’s estimates regarding over payments to providers.  Authorizations and payments take longer under this ASO than before.  

Some programs have had to hire new staff to help with the volume of administrative work. This is not an efficient way to run any business, let alone a healthcare program during a pandemic.  It is important to note that while we have bene focused during this hearing on the impact of Optum’s failure on treatment programs, Optum also administers non-clinical funds, including payments to recovery residences. They too have suffered the one-two-punch of a dysfunctional ASO and a pandemic.

Q&A:

Del. Reznik: Can you go into a little more detail about what providers are facing with regard to having to go through the process of reconciliation and ultimately what is the concern from providers if reconciliation doesn’t work, if they have to pay back millions of dollars? What is going to be the effect on the provider community if this process is drawn out or fails.

Lauren Grimes: I think there are a number of challengers to records reconciliation.  There are four industry standard reports that guide revenue cycle management for providers, and three of them are not working. Providers are incapable of checking Optum’s math and we are dealing with an apples to oranges issue where many providers have been overpaid or been paid twice for claims submitted during the estimated payment, or either been significantly underpaid for new claims. Those things need to be balanced out and we don’t have the tools to be able to follow those claims through each reprocessing iteration that they have gone through. We have no confidence that the numbers we are receiving from Optum are indeed correct and there needs to be transparency through this process.  

Dave Smulski 

Current Law

• State law enacted in 2009 and expanded in 2010
• A hospital must submit its debt collection policy to the Health Services Cost Review Commission (HSCRC), and it must include:
  • Oversight of a contract to collect debts
  • Prohibiting selling debts or charging interest for self-pay patients before a court judgment
  • Describing procedures for considering patient income and assets, debt collection procedures, and circumstances for seeking judgement
  • Procedures for remedying debt collection actions, including refunds, against patients determined to be eligible for free care
  • Procedures for patients to dispute hospital debt collection actions. 
• Patient refunds, eligibility for free care
  • A refund must be provided within two years of date of service if the patient was eligible for free care
  • The time may be reduced to no les than 30 days after patient information is requested if the patient does not cooperate with the hospital’s request
• Reports to consumer reporting agencies or civil actions
  • No report or action may be made about a patient for 120 days after billing unless the patient does not cooperate with providing the information requested by the hospital
  • A hospital must report a patient’s debt fulfillment to a consumer reporting agency within 60 days
• A hospital is prohibited from forcing the sale of, or foreclosing on, a patient’s residence to collect a debt; liens, however, are authorized
• Procedures for hospital delegation of debt collection to an outside agency
  • Collection activity must be specified by contract and must  be consistent with a hospital’s debt collection policy
  • A contract must include procedures if a patient appears to qualify for financial assistance
  • The debt collection agency must establish complain procedures for the patient to follow and must forward the complaint to the hospital

American Hospital Association Guidelines:

• Guidelines established in 2003 and last revised in 2019
• Hospitals are encouraged to review billing policies and procedures, and how these policies and procedures are presented to patients and the public.
• The guidelines consist of action plans, resources, and specific federal requirements for tax-exempt hospitals
• For action plans, hospitals should:
  • Consider a bill from a patient’s point of view
  • Review communications to patients regarding billing and collections, personnel actions, financial assistance policies, and complaint procedures
  • Engage governance boards and staff about the hospital’s patient billing and debt collection practices
  • Review compliance with IRS 501(r) requirements that tax-exempt hospitals must comply with on financial assistance and billing and collection practices
• Resources:
  • Hospital should use the 2012 Hospital Billing and Collection Practices Statement of Principles and Guidelines, developed by the American Hospital Association (AHA) and other national organizations, which hospitals should abide by when assisting patients navigating payment for services, including financial assistance, and ensuring fair billing and collection practices
  • Other guides that should be consulted by a hospital include the Healthcare Financial Management Association’s (HFMA) Patient Financial Communications Best Practices  released in 2016, and AHA’s and HFMA’s jointly developed Avoiding Surprises in Your Medical Bills: A Guide for Consumers, and Understanding Healthcare Prices: A Consumer Guide
• Federal Requirements for tax-exempt hospitals
  • In order to maintain tax-exempt status, hospitals are prohibited from taking “extraordinary collection actions” before making reasonable efforts to determine a patient’s eligibility under its financial assistance policy
  • The prohibition also applies to any purchaser of a patient’s debt including debt collection or similar agencies
  • Extraordinary collection actions, which also apply to collection agencies, include reporting information about a patient to credit reporting agency, foreclosing on property, and commencing a civil action
  • A hospital is required to resume that a patient is eligible for its financial assistance policy
• According to the Association of Credit and Collections Professionals, 1 state have laws or initiatives relating to hospital billing and debt collection
  • California
    • A hospital may not make a report to a consumer reporting agency or take any other action until 150 days after billing
    • State law limits wage garnishments or liens on primary residences
    • When a hospital received notice of Medi-Cal (California’s Medicaid Program) eligibility, a debt collector must immediately cease collection activities
  • Colorado
    • A hospital must provide written notification to a patient, at the patient’s last known address, 30 days prior to initiating collection actions
  • Connecticut
    • Hospitals are prohibited from collecting more than providing the cost of the service from the patient
  • Illinois
    • A hospital may not refer a patient to a collection agency unless the patient is given the opportunity to request a “reasonable payment plan”
  • Minnesota via a consent decree
    • Each medical bill must be reviewed by the hospital before collection actions commence
    • Collection agencies must be under direct contract with a hospital and do not have “blanket authorization” to pursue garnishments or other actions against a patient. 
  • Nevada
    • Hospital debt collection may not commence sooner than 30 days after a notice was sent to the patient that a bill is due
    • Any interest charge on patient debt is limited to the prime rate, plus 2%
  • North Carolina
    • Upon a patient’s request, a hospital must provide an itemized list of charges to the patient in plain language
    • An unpaid patient bill may not be referred to a collection agency while eligibility is pending for charity care
    • Hospital debt collection may not commence sooner than 30 days after a notice was sent to the patient that a bill is due

Health Facilities – Hospitals – Medical Debt Protection (HB 1081)

• • HB 1081 adds to, expands, and specifies existing State hospital debt collection policy law
  • Modifies hospital debt collection policy reporting to HSCRC
    • Providing a patient with the ability to modify a debt payment plan
    • The policy must prohibit the hospital from collecting debt that exceeds the cost of services for patients eligible for the financial assistance policy
  • Establishes interest on hospital debt
    • Interest limited to 1.5% per annum
    • No interest may be charge for a patient eligible for the financial assistance policy
    • No interest accrual until 180 days after the later of discharge or the end of a regular billing period
  • Installment payment plan provisions
    • Each patient incurring medical debt Must be offered an installment payment plan 
    • The plan must be offered before discharge, with the hospital bill, on request, and with each written communication regarding debt collection
    • There are limits on the amount of monthly payments (5% of income) and repayment periods (36 months) 
  • Reporting to a consumer reporting agency provisions 
    • Increasing from 120 to 180 days with NO exceptions 
    • No reporting if the patient was eligible for the financial assistance policy 
    • No reporting or delegating collection activity if the hospital knew or reasonably should have known a decision regarding a patience eligibility was under appeal or review 
  • Prohibited actions by hospitals expanded 
    • Liens are prohibited 
    • No debt collection actions may be taken until 180 days after nonpayment 
    • Note debt collection actions are allowed for patient debts of $5000 or less 
  • Added provisions for authorized debt collection actions by hospitals 
    • 45 days before a hospital takes a debt collection action, written notice of the intent must be sent to the patient 
    • The debt collection process and contents of the written notice are specified an include sending the notice by certified Mail; The notice must be in simplified language and, if applicable, the patient’s preferred language 
    • The written notice must be accompanied by an application for financial assistance under the hospital’s policy 
  • Additional provisions for authorized debt collection complaints to a court by hospitals 
    • Each complaint must include an affidavit that includes the date the 180 day. Lapsed and that the hospital met its obligations regarding notifying the patient and determining that the patient was eligible for financial assistance 
  • If a hospital uses a debt collection agency, both the hospital and debt collection agency are jointly and severally responsible for meeting the law’s requirements 
  • Hospitals are required to report specified debt collection information to capital HSCRC, and the commission must post the information on its website  

Q&A

Del. Young: Could you tell me what process is in place to educate a patient on their ability to qualify for financial assistance or to review the process for finding resources, and how do you monitor that process overtime to make sure that the patient receives some counseling and an awareness of opportunity? 

Smulski: There’s nothing in the law about financial opportunity awareness. 

Del. Cullison: In terms of eligibility for financial assistance… are there provisions for those who become financially eligible for assistance after a procedure/service is rendered?  

Smulski: There is nothing in the law that specifically addresses that situation. I have heard that this is becoming a concern because of the pandemic. The law is silent right now on how long you can be eligible for financial assistance. 

Del. Heath…: In terms of change status not just in your financial status but if the law speaks at all to change of household status because that would obviously change your financial situation.

Smulski: Again, there’s really nothing in the law at least in debt collections about change in status. 

Maryland Hospital Association
Hospital Solutions on Consumer Cost

Jennifer Witten
Bob Atlas – will be speaking from the consumers perspective
Godlee Davis – President and CEO of Deco Recovery Management

Bob:

In Maryland, from 2013 to 2019, premiums rose 24%, deductibles grew 55.6%

Insurance complicates billing and payments

Godlee Davis: 

Steps and Practices that are common among a lot of the hospitals for assisting patients with financial assistance:

Enhancements to Financial Assistance Process in Response to Passage of HB1420 in 2020:

• Increased financial eligibility threshold to 500% of Federal Poverty Level (FPL) 
  • most hospitals already included up to 400% of FPO 
• Excluding certain assets such as 
  • Any resource excluded from Medicaid Eligibility determination 
    • MAGI (under 65 and not disabled) qualifications do not count assests
  • Retirement Plans
  • First $10,000
• Developed plain language financial assistance summaries in multiple languages 
• Developed consumer complaint and appeal process (HSCRC & HEAU)
• Preparation for Annual Financial Assistance Report

The following slides are examples of patient profiles for financial assistance policy applications:

Key Takeaways & Hospital Field Policies & Practices

Hospital Financial Assistance & Billing Processes: Survey Results

Path Forward:

• Maryland leads
  • Our hospitals’ practices equal or best other states
• 2020 legislation continued Maryland on this path
  • Revised hospital financial assistance policies
  • Disclosure of outpatient facility fees
• Hospitals strive to mitigate consumer cost exposure
  • Simplified billing
  • Payment plans
  • Transparency
  • Notice

… without threatening Maryland’s unique Total Cost of Care model

Del. Lewis: You gave some great examples/case studies; there was a case study you referred to in which a patient was experiencing homelessness and seen in the ER, and you described a process in which that person would apply for financial assistance. My question is, why wasn’t that patient immediately deemed presumptively eligible for Medicaid?

Davis: Unfortunately the Medicaid process does not enable this automatic eligibility. 

Del. Carr: I read that Johns Hopkins Hospital has stopped filing lawsuits against patients for medical debt and if that is true what is to stop additional members from following that practice?

Atlas: I don’t know the answer to the question on Hopkins, but I can say that we have a number of members that don’t sue, that is a choice of the individual institution. Both federal and state laws do require hospitals to pursue collections.

Del. Carr: The ones that don’t sue, do we know if they are worse off than the ones that do?

Atlas: I can look into that. This is a changing process. 

Del. Cullison: If the person reaches that 500% FPL, would they then be automatically given the assistance that is not clear?  

Davis: With regards to the presumptive and eligibility, it is defined in the hospital policy, and when they do that eligibility check and it comes back that patient is under that threshold, then yes; happens automatically.  The difference is that that occurs sometimes at multiple stages for the patient, and at different times for different hospitals. in some instances it may occur at 90 days, it may occur in 120 days… there could be a difference in that process and so it’s really just a matter of when that happens, but it’s always occurring before the collection efforts begin and once it happens if the information is available to determine if they meet the criteria.

Del. Cullison: I’m concerned about inconsistency among the hospitals.

Del. Krebs: With regard to the type of debt that we are trying to collect, you talked about copays and deductibles is there some kind of report that shows you where the debt is coming from, whether it’s those types of things, whether it’s facility fees?  Do we have any idea of where the majority of this new debt is coming from? 

Brett McCone: I think what we’ve seen recently is the hospitals do have that information. The expansion of the high deductible plans with the out-of-pocket coinsurance and deductibles certainly we’ve seen a large increase in uncompensated care from the growth in those plans.

Maryland Health Services Cost Review Commission
HSCRC Update on Financial Assistance and Debt Collection Activities

Tequila Terry, Principal Deputy Director at the HSCRC

Q&A:

Terry: There are a variety of thresholds that exist relative to current qualifications for free care, reduced care, reduced cost care for parents with a hardship.  For free care the current threshold for qualification is at 200% FPL; for reduced cost care it is at a threshold of family income between 200 and 300% of FPL; for reduced cost care for patients with financial hardships that is where it comes to the 500% FPL; for medical debt that exceeds hardship, the debt has to exceed 25% of family income to qualify. It depends on the type of program that depends on the actual threshold.

Del. Lewis: Are we on track to get your final analytical report by December 31st 

Terry: We just got the data within the last 7 days. I would love to have our team look at the data and make sure there are no issues.  I reserve the right to perhaps come back to the committee if we have issues.