ASG Perspectives

On-Call with Sara Winand, RN: Rates for Air Ambulance Services Taking Off

Thursday, August 30, 2018

 

 

A recent issue of MyHealthGuide newsletter has put the spotlight on air ambulance regulation. In fact, the Health Care Administrators Association (HCAA) and Society of Professional Benefit Administrators (SPBA) recently initiated a targeted letter-writing campaign focuses on rising air ambulance transportation costs for self-funded health plans.

 

Without reform, America’s families, health care providers and the self-funded community face an increasing and often conflicting set of rules and regulations that fail to provide any semblance of financial certainty when life-saving air ambulance services are employed.

– HCAA and SPBA

 

Air ambulances are typically covered by health insurance if determined to be medically necessary, and if the service is limited to the nearest appropriate medical facility. Fees are generally not covered if the air ambulance is used solely for convenience. Almost all air ambulance services are out of network, and since the service must typically be arranged under urgent circumstances,any pre-service negotiation is rarely an option.

At ASG, we’ve seen first-hand instances in which air ambulance charges have skyrocketed into outrageous dollar amounts, especially when used in urgent situations and provided by non-network vendors, oftentimes without precertification. Many times a deposit is requested from the patient/family and without a signed negotiation the member is balanced billed.

For example, we recently worked with a claimant who had an accident in Georgia and was hospitalized there, but needed a specialized rehab facility for recovery. We soon learned there are only fourteen such facilities in the country; the closest location was quoting a three-week waiting period; and due to the woman’s condition, air transport was the only option to get the claimant to any of the other thirteen. On top of these obstacles, the employer group’s plan did not require a precertification for the service.

The claimant was ultimately transported from Atlanta to a rehab center in Chicago. The air ambulance bill: $258,000. Thankfully we were able to negotiate the claim to $136,000, even though the air ambulance company was pushing for immediate payment.

These numbers are not unexpected. A recent study conducted by the Montana Legislature broke down air ambulance costs into two main parts: liftoff fees and per-mile charges. While the former ranges between $8,500 to $15,200, the latter can be anywhere from $26 to $133 per mile. These variable charges are based on distance and staffing needed for the transport.

We and others in our industry are keeping a close eye on Sentinel Air Medical Alliance, an alliance of healthcare payors established in response to the rapid escalation of air medical transport rates. Sentinel's goal is to provide solutions for effectively controlling rates and ensuring proper utilization of air transport services. The alliance's areas of focus include prior authorization for air ambulance services, medical review of transport claims, claim negotiating and repricing, and consulting services to help healthcare payors develop strategies to control air ambulance costs.

Global Emergency Services provided by Assist America are included with every ASG sold stop loss policy. These services are a supplement to the health plan but it is imperative to contact them to make arrangements such as air ambulance as they cannot reimburse for arrangements made by another party. For more information on Global Emergency Services go to http://www.assistamerica.com/.

 

 


SPOTLIGHT ON: INTERLINK COE Networks & Programs—Proactively Managing Plan Expenses

Monday, February 05, 2018

 

There’s a rapidly growing company in Hillsboro, OR, that’s been around for 23 years and is currently on the brink of changing the world.

Well, the world of cancer care management—which could prove to be monumental for all of us in the healthcare insurance industry.


For over 23 years, INTERLINK COE Networks & Programs has provided transplant network services for reinsurance carriers, insurance companies, self-funded employers, and other managed care clients in the United States.

INTERLINK is an established Center of Excellence-based company that recognizes the value of ensuring geographic coverage of evidence-based care protocols for plans across the nation. Its Centers of Excellence network provides access to high-cost, low-frequency medical procedures used by health plans of a range of sizes.

The company was founded by John Van Dyke, a former PPO negotiator, in 1995. In 2010, INTERLINK saw an opportunity to work with reinsurers to develop targeted cancer care management programs into the Centers of Excellence model.

INTERLINK’s CancerCARE program extends the firm’s Center of Excellence networks with specialized cancer case management nurses who provide consultative support for members looking to choose providers and seek treatments. Targeted cancer benefit language for employer plans is also included at no cost.

“Cancer is the number one employer-paid stop-loss deductible; number one reinsurer reimbursed claim at all levels; and also the number one cause of bankruptcy for members who are covered,” notes Van Dyke.

During a time when health plan premiums have increased 7% to 9% per year, the cost of cancer treatment has jumped an average of 20%. Van Dyke adds that health plans have no control over the frequency of cancer diagnoses, but can influence care quality with benefit incentives and definitions when inserted in the plan document.

However, he believes, there is an opportunity to control costs and increase optimal member outcomes, simply through improved quality of treatment. Better treatment translates into minimized complications and risk of reoccurrence—and ultimately, lower plan costs.

“Our CancerCARE program, from a plan level in managing cancer, is the number one investment that a plan could make to manage their members’ cancer care,” he says.

In 2018, the company CEO estimates the expected frequency of transplants will be 14.66 per 100,000 insured members; and of those 14.6 forecasted transplants, nearly half (6.0 of 14.66) will be for a cancer-related diagnoses.

“With benefit caps removed, a single poor outcome transplant can now cost the plan many millions,” says Van Dyke, “but if you put the CancerCARE benefit language in your plan, you could identify 41% of your transplant cases proactively. With this early notice, you can better manage your expenses within the plan."

Taking Risk Management to the Next Level

“Once you put CancerCARE in your plan, you’re already managing your transplant risk.”

–John Van Dyke, CEO

INTERLINK’s TransplantCARE and CancerCARE programs are based on performance narrowed concepts through networks that are built on “value-driven principles, the best providers, and timing for the best cost,” says Van Dyke. “When you performance narrow with INTERLINK, and outcome improving your very low-frequency, high-cost medical procedures, we’re not disrupting care, but improving member decision quality.”

The Data Tell the Story

The INTERLINK performance model addresses all solid organ transplant programs. The data-accepting capabilities of the model was extended in 2017 to accept transplant outcome data for all transplant teams throughout the U.S.

“We’re looking at 25 of the most telling outcomes for all transplant teams,” explains Van Dyke. "Which identifies for us those transplant teams posting the best outcomes.”

That data, says Van Dyke, "comes to us risk-adjusted by transplant center and team—so we have the cleanest data set in healthcare to rank the lowest-rated to the number one outcome provider in the country.”

For example, should a covered member require a liver transplant, he explains, “INTERLINK’s narrow-performance network directs them to a facility where the surgical team is high-performance, high-competency. We’re looking for a great member outcome, which almost always comes with a lower cost.”

A New Era in Cancer Care Management

As Van Dyke continues to work with brokers, consultants and health plans of all types to incorporate the Centers of Excellence model to cancer treatment, he understands that the healthcare market can be slow to adapt to new concepts. Yet after nearly three decades working in the business, he is confident INTERLINK’s solution is about to have a significant impact.

“I see the cancer care and transplant programs as examples of today’s most important initiatives,” he says. “Our focus is on quality care, and the outcome of quality care is reduced price. So if healthcare moves on this pathway, I believe this is how we’re going to solve our healthcare crisis.”


 

On-Call with Sara Winand, RN — Let's Get Creative with Corporate Wellness

Thursday, January 04, 2018

Many wellness programs offer paid time off as a reward for completing certain ongoing tasks—like taking so many steps in a designated two-week period can earn an employee one hour of PTO. For example, Blue Cross Blue Shield South Carolina offers its Get in the Habit of Moving More Challenge to help employees move toward better health. We started looking into this trend, and discovered the following article from Benefits Broker Pro, which we thought would be of interest to any TPA or Broker looking to offer a new twist on corporate wellness.

 

Corporate wellness is having its moment 

A cloud has been hanging over the corporate wellness industry, in no small part due to an often-cited RAND study which shows wellness programs are having little to no effect on reducing employer health costs.

Findings like this spell bad news for wellness solutions, not to mention for the HR departments that have invested billions in them. Does this mean it’s time to throw in the towel? Hardly.

Reverting to business as usual isn’t a winning strategy. Chronic illness, health costs, and lost productivity are all on the rise. Companies that ignore these issues do so at their peril.

All of the above is why I believe in 2017 the wellness industry is having its moment. While the initial hype behind wellness has led to serious disillusionment, we are now at a pivotal turning point, where thoughtful approaches, as well as some hard-learned lessons, start leading to real results.

Lesson #1: Stop creeping out your employees

All too often, wellness programs alienate employees long before any progress can be made. This usually begins with the health risk assessment -- a deeply flawed but widely used tool. These impersonal assessments ask employees to answer invasive questions like, “How many times do you cry per week?”

Lesson #2: You can’t force employees into better health

If your employees believe they are being forced into a program or penalized for not participating, that new Fitbit you’ve rolled out can quickly look like a pair of handcuffs. It’s crucial instead to nudge employees into wanting to participate and be proactive in maintaining or improving their own health.

This level of trust and engagement will never happen in a program where employees feel berated for not losing enough weight or taking too few daily steps. Wellness programs must dig deeper to determine what employees want and what will motivate them to achieve long-term health goals.

It’s important to remember trust goes both ways. Allowing employees to opt-out if they aren’t ready is a leap of faith employers must be ready to take. The focus for these non-participants then becomes determining what they need to feel ready and capable of improving their health.

Sound like a lot of effort? It is. But the alternative is failure. A mandatory, punitive wellness program ultimately won’t create positive engagement or meaningful behavior change.

Gym stipends and other perks such as on-site yoga classes are great. Companies should absolutely offer them if it makes sense for their employees. But workout perks can’t be the final word in a wellness program. Social determinants of health should factor in, too.

If an employee is dealing with anxiety that makes getting out of bed a daily struggle, what good will a gym membership do them? In addition to exercise and nutrition components, a wellness program should fulfill behavioral health needs. Services such as stress management workshops, financial counseling, and substance abuse treatment can make a world of difference in the health of employees.

Lesson #4: Culture is king

What these lessons have in common is that they are all points to consider before rolling out a wellness program in the first place. To that point, there is no value in offering a program until leaders have a thorough understanding of their company’s culture.

I tend to view corporate culture as the iceberg that lives beneath the surface of any wellness program investment. Culture single-handedly determines how much ROI is observable at the top. Companies which lack strong cultures -- where employees feel valued, believe in their company mission, and trust peers and leadership alike -- will continue to see their investments in wellness sink, dragged down by internal dysfunction, fear and mistrust.

There’s no quick and easy way to make wellness programs work, but the right formula is simple. Successful programs accurately reflect employee health needs at the individual level, are built on solid work cultures, and engage employees in a spirit of co-creation. When these dynamics are in place, a wellness program is primed to provide useful, personalized solutions which lead to a healthy return on investment for employees and the company alike.

 

On-Call with Sara Winand, RN — Sleep: It Does a Body Good!

Thursday, October 12, 2017

Aahh.... sleep.

We all love it, but sleep quality can make the difference between a productive worker and an on-the-job snoozer.

Translated into dollars, a 2011 study by the Associated Professional Sleep Societies found that poor sleep quality can result in a productivity loss of $2,280 per worker, per year.

In addition to improving employee retention and reducing absenteeism, good sleep habits among employees can no doubt have a profound impact on your organization’s bottom lin. Well-rested employees report that they are happier, less stressed, and more focused on the job, compared to their sleep-deprived colleagues.

In particular, a new study recently released from the American Heart Association has found sleeping less than six hours a night could more than double the risk for death for people with metabolic syndrome!

Do you or someone you care about have metabolic syndrome? People that have at least three of the five following conditions, have metabolic syndrome:

1. Abdominal Obesity

2. High blood pressure

3. Elevated fasting blood sugars

4. High triglycerides

5. Low HDL levels (the good cholesterol) or high triglyceride levels

Having this syndrome puts you at higher risk for cardiovascular disease, stroke and type 2 diabetes. The increased risk for death as it relates to less sleep was associated with all five factors, although findings show the sleep effect is strongest among those with high blood pressure and high fasting blood sugars.

Metabolic syndrome is preventable, so to reduce your risk and not become a statistic, consider taking the following steps toward prevention:

– Eat better: whole grains, fruits, veggies, lean meats, fish; avoid processed food

– Be active: exercise or walk, and put at least 150 minutes per week into your routine

– Lose weight by combining healthy eating with healthy physical activity

– Take prescribed medication to control blood, pressure, blood sugar and cholesterol

– Track your sleep habits with wearable tech devices

– Get 7-8 hours of sleep per night as recommended for adults (and that does not include naps!)

Encourage your employer groups to take advantage of the many types of wellness programs and health screenings offered by professionals within their communities to identify risk factors early before they cause major complications such as heart attack, stroke, atherosclerosis, poor healing, or renal failure.

Still not convinced? Check out this segment that was recently aired on CBS This Morning explaining how sleep affects people with metabolic syndrome. 

 

On-Call with Sara Winand, RN – Pediatric Neuroblastoma: Wow!

Friday, January 27, 2017

Neuroblastoma is a tumor that develops from nerve tissue, most commonly in the adrenal glands, and affects mostly infants and young children. It is staged I-IV and categorized as low-risk, intermediate-risk and high risk.

– Children with low-risk disease can be treated with surgery, and a complete resection is usually achieved.

– Intermediate-risk disease treatment includes combined chemotherapy and surgical resection.

– For children with high-risk neuroblastoma, there have been substantial improvements with aggressive combination modalities. These generally include chemotherapy, surgical resection, high-dose chemotherapy with stem cell rescue, radiation therapy and biologic/immunologic therapy (e.g., Unituxin® (dinutuximab*)). These approaches have improved event-free survival, but unfortunately, many are at high risk for relapse of their disease.

Let me share a brief summary of two high-claim cases we have followed recently. In cases like these, it’s difficult to anticipate ongoing costs.

CLAIMANT # 1:

2015

Imagine having a newborn just four months old diagnosed with stage IV neuroblastoma per exploratory laparotomy, liver biopsy and bone marrow biopsy. The chemo regimen required inpatient confinement, then another confinement for low blood counts. Two months later, after chemo was completed, they began stem cell harvesting in preparation for the planned autologous stem cell transplant. Scans showed residual tumor with incomplete response and the baby was admitted for excision of the residual tumor. High dose chemo and autologous stem cell transplant followed surgical recovery.

2016

This young child unfortunately had suffered post stem cell transplant complications and required home TPN, but was eventually weaned off and able to undergo radiation to the liver and primary site. With reevaluation and family conference, the decision was made to proceed with immunotherapy treatment regime with Unituxin® (dinutuximab*). This required inpatient care for the infusion therapy and paid claims varied from $65,000 to $175,000 per admit. Post treatment complications required acute care, but by August, the medical team was able to report no recurrence or progression!

The outcome was the good news, thanks to the fact there was a global transplant policy that covered the autologous stem cell transplant.

The bad news was the claims incurred.

– In 2015, the seven months of treatment (excluding the stem cell transplant, which was covered by the global contract) billed charges were $763,196. The TPA paid $341,644 from ground up.

– In 2016, with six months of treatment, billed charges were $1.6 million and the TPA paid $750,000.

CLAIMANT #2:

2015

This seven-year-old was diagnosed with high-risk neuroblastoma in mid-summer 2015 and began treatment with induction chemo, requiring multiple hospital admits followed by surgical resection/adrenalectomy with lymph node dissection in late November. A tandem autologous stem cell transplant after recovery was also planned, with an Optum transplant contract placed with Boston Children’s Hospital.

2016

The child was admitted in March 2016 for the first stem cell transplant (paid $280,000) and readmitted the next month for the second stem cell transplant (paid $203,000). Post-transplant chemo of five cycles began in July, requiring four to five days of inpatient care. She was hospitalized for 18 days in August (paid $140,000) with hypertension and thrombotic microangiopathy (clots in small blood vessels) and has been treated with the monoclonal antibody Soliris® (eculizumab). Other complications required inpatient care and intensive outpatient care, and the eculizumab treatments remain ongoing every two weeks ($35,000 to $40,000 per treatment).

– Claims in 2015 billed $825,000 and the TPA paid $425,000.

– Claims in 2016 billed $2,176,303 and the TPA paid $1.8 million. Claims will be ongoing in 2017.

Although treatment outcomes are dependent on tumor characteristics, age and extents of metastasis, it is interesting to note that infants less than one year of age have a better survival rate than older children.

 

*On March 10, 2015 the U.S. Food and Drug Administration (FDA) approved dinutuximab, which is a monoclonal antibody against GD2, for use in the treatment of high-risk neuroblastoma. It was approved as part of a multimodality regimen, including surgery, chemotherapy, and radiation therapy, for patients who have achieved at least a partial response to prior first-line multiagent. It is indicated in combination with granulocyte-macrophage colony-stimulating factor (GM-CSF), interleukin-2 (IL-2) and 13-cis-retinoic acid (RA) for pediatric patients with high-risk neuroblastoma.

 

Mental Health & Substance Use Disorder – Who’s Abusing Who?

Wednesday, July 27, 2016

by Sara Winand, RN, Director of Medical Management

The Mental Health Parity and Addiction Equity Act of 2008, which went into effect January 1, 2010 has changed the way Mental Health and Substance Use Disorders are viewed and paid by employer groups.

Cumulatively, a series of changes and trends have been having a serious impact on our mutual abilities to underwrite a competitive policy that works to support our employer groups’ businesses – not cripple their budgets.

The impact of Health Care Reform is extensive. The act mandates:

  • – No annual dollar limits
  • – No lifetime maximums
  • – No annual limits on number of days or visits
  • – Coverage extended to dependents up to age 26

We are now seeing covered individuals seek treatment for Substance Abuse more and more frequently, with costs for treatment ranging from $150,000 to $300,000 – for a single year.

In fact, in the six years since the Act passed, the group for which we’ve seen a growing trend in high claims is 16- to 26-year-olds! This age group is the highest risk category for relapse and ongoing charges, and has become a financial liability to plans and excess carriers across the U.S.

Why? Here are a few trends that may answer that question:

  • – Mental Health (which includes Substance Use Disorder) is now a covered benefit just like any other illness.
  • – Although many facilities have been out of network in the past, we are seeing a trend for now in-network claims for Substance Use.
  • – Facilities are now outsourcing labs, so urine drug screens are billed separately and frequently (many times daily) and often cost as much as the facilities’ daily charges.
  • – Facilities are billing incrementally, meaning these charges are flying under the radar and are not readily detected as a potential LARGE claim.
  • – Many plans only require precertification for inpatient acute care and can go unmonitored when the claimant steps down to Residential, Partial Hospitalization, IOP (Intensive Outpatient) then to OP.
  • – Facilities are typically located out of state; many resemble a resort: They are lined with palm trees, feature seascape landscaping, and offer 4-star cuisine, recreation and exercise programs which oftentimes include yoga, horseback riding, spa therapy, and more.
  • – Many websites feature logos of PPO networks but are not actually affiliated with these or any network.

As partners invested in protecting our employer groups’ interests, it’s important that we do what we can to stop the bleeding. Try asking the following questions when you see claims related to Mental Health or Substance Use Disorder treatment:

  • 1.Is this person’s treatment court-ordered?
  • 2.How is this treatment being certified for medical necessity?
  • 3.Is the facility licensed for the diagnosis and services it is billing for?
  • 4.Does the facility bill for IOP more than five days a week?
  • 5.Should I have claims and the medical records sent out for review before paying the claim and submitting to stop-loss? This is highly recommended.

With the lethal cocktail of health care reform, lack of financial limits, and mandatory coverage to age 26, it is anticipated that Mental Health and Substance Use Disorder claims will only become more prevalent.

Please contact us at info@asgrmi.com and let’s work together to try to reduce the financial risk these trends can pose to our employer groups.

 

Lasers: Finding the Balance Between Risk and Reward

Wednesday, June 08, 2016

by Nathan Savage, Underwriter and April St. Cyr, Claims Manager

As we hear more and more people talking about stop-loss policies, the hot topic that keeps coming up seems to be lasers.

In its simplest form, a laser involves adjusting the stop-loss deductible for an individual who has a very high likelihood of exceeding the group’s regular individual specific deductible.

Lasers can present the group with additional liabilities – but as with any insurance, the coverage is for unknown risks, rather than known risks. There is also a cap that when hit, would start reimbursements. This allows a group to have a max cost, even on riskier members. (For example, we may have a laser of $250,000 for a cancer diagnosis but if the member’s claim goes over that amount, we still reimburse over the laser.)

Lasers can also be conditional, and are typically based on events such as transplants or chemotherapy. When this is the case, the covered member must meet the group’s specific deductible for anything that does not pertain to the condition set.

So when are lasers considered?

We start looking at members during the underwriting process. If there are obvious claimants who we predict will be over the group’s deductible, we make a note of it on our initial quotes.

Lasers are finalized when a group’s disclosure is signed and sent to us with supporting documents. The disclosure is an important tool that gives us an accurate and detailed picture of all known claimants or high-risk individuals. It’s also the last time that we look at the group to set lasers.

Click here to read more about the role disclosures play in the underwriting process.

Limiting exposure to all parties involved

When a notice is received on behalf of a high risk member, our Medical Management team reviews the notice using the following typical reporting:

– High claim reports

  • – Pended reports
  • – Pre-certification reports
  • – Case management reports

Based on the findings in these reports, we further research costs using web-based tools that provide critical information (such as clinical and financial analytics) and help with managing, reimbursing, and underwriting catastrophic claims.

Our team may also reach out to the TPA or case manager for any additional questions or information pertaining to the group in general, or the claim in particular.

And that’s not all.

ASG has established relationships with leading vendors who are willing to work with us, our TPA partners, and the employer group to secure deeper discounts for coverage of high-risk members.

Often, a medical bill review and audit company, or a medical cost containment and claims flow management organization, is able to negotiate with a provider and get sign-off on a rate that benefits all parties. Transplant networks for solid organ and bone marrow transplants offer excellent contracts to help mitigate the financial sting of complex care.

When Lasers Meet Claims

As we stated above, the laser is conditional and therefore specific to the covered individual. Following is a typical example.

Say Sue Smith’s policy includes a $150,000 conditional laser in the event of chemotherapy, and her employer group carries a $50,000 regular deductible.

If Sue undergoes a chemotherapy regimen and meets her laser of $150,000, our TPA partner would send in all required reporting for filing a claim as it would for anyone on the plan, regardless of a specific deductible. Our claims analyst would review and process the claim the same way as if there were no laser.

On the other hand, if Sue goes in for a knee replacement – which obviously is different than chemotherapy – and the knee replacement costs $70,000, we would simply reimburse the company the $20,000 difference over their deductible.

No matter the size of the policy or number of lasers included, what’s most important to an MGU like us is confirming that the claims:

  • – Are paid according to the plan document
  • – Meet all requirements of the stop-loss policy

At the end of the day, our goal is to write and stand by a policy that works for all parties involved.

We’re here to answer your questions about lasers. Contact us at any time! 

 

ASG Welcomes New Team Member

Tuesday, January 19, 2016

We’ve added a medical specialist!

Sara Winand, RN, has been named Director of Medical Management, responsible for medical underwriting support and proactive claims management for ASG clients.

 

 “I have always enjoyed the continuing challenge of assessing each case individually,” she said. “It requires daily research of new trends, new procedures and treatments and their costs, covering all health conditions.”

Sara brings more than 35 years of healthcare experience to our team, with 16 of those specific to the stop-loss insurance field.

“Our firm is recognized nationwide for our focus on high-touch customer service, which allows us to administer claims proactively while protecting employer interests,” said Peter Parent, President of ASG. “Sara provides our TPA and Broker clients with an experienced, knowledgeable resource for helping to control employer costs and achieve the best possible outcomes for everyone.”

 

 

 

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