Ohio Aging Services Network

Ohio Aging Services Network

Contracting Update

10/9/17

We have provided a grid containing the outline of each payor negotiation. The most current information is in red.

Highlights:

Aetna

The Aetna contract was signed by Jim Formal last week, and returned to Aetna for counter signature. Once we have the fully executed documents in hand, we will forward a copy to each participating facility along with a summary of the major provisions to use on a daily basis.

We have also developed a flow document that will help providers determine the level of care that each patient will fall into and the rate of reimbursement that will be assigned. This will be distributed along with the contract documents, and prior to the educational inservice which will be held on Wednesday, October 25th at 10:30 a.m. We have provided notice to the facilities, and will be following this with a calendar invite.

We have copied the rates included in this contract below:

Level I $375

Level II $425

Level III $460

Level IV $600

Outpatient services will be at 115% of the AMFS fee schedule

In addition, Aetna did agree to accept all OASN facilities regardless of star rating, and all facilities did agree to participate with the exception of one.

We met with Aetna this week. We had two language revisions that had not made it into the final document. They got them corrected, and we are awaiting the final documents inclusive of the provider listing with all OASN facilities loaded with the exception of one that opted out.

Again, we will be providing a webinar to go through this contract in detail, so we can educate your clinical and billing staff on how to navigate the different levels of care and reimbursement.

Aetna did respond in regard to the accreditation language that states that all facilities must be accredited by JCAHO, CHAP, etc. They are only requiring Medicare certification, but since some facilities are accredited, we didn’t want to simply remove the language. So, they agreed to alter the language stating that facilities MAY be accredited.

In addition, I did receive clarification regarding the language in the Medicare Amendment as listed:

Pursuant to Section 5.M. of this Addendum, Provider certifies that the diagnosis codes submitted to Company for Medicare Members that Company is required to submit to CMS will be accurate, complete and truthful (“Certification”). Provider acknowledges and agrees that Company may impose a penalty on Provider not to exceed five thousand dollars ($5,000) for each instance that Provider submits a diagnosis code to Company for a Medicare Member that does not comply with this Certification because the diagnosis code was not submitted in the format described in 42 C.F.R. § 422.310 or any subsequent or additional federal regulations. For purposes of this Section, “diagnosis code” shall mean an International Classification of Diseases-9th Edition-Clinical Modification (ICD-9-CM) code or its successor.

Per Aetna, they cannot remove this language, but they did reiterate that this is not intended to punish facilities for billing errors. They understand that mistakes happen. The intent of this language is for them to have a penalty for facilities that have a pattern of submitting incorrect or fraudulent billing information. There would be a process they would implement to notify the facility in advance of taking any action. We have had providers that have been contracted with Aetna for years and have not had an issue with this.

The last part of the contract being negotiated is the Aetna Market Fee Schedule. They provided the entire fee schedule and of course, the codes pertaining to outpatient therapy are the ones important to the OASN facilities. As Aetna would not agree to a different methodology for these services, we did counter with 120% of the fee schedule. They are currently reviewing this, and will let us know their findings.

Once this last piece is finalized, the contract will be completed. We will send for a final vote to all of the members.

As you know, we have been working with Aetna on rates and language. We were able to make a very compelling case to them on behalf of OASN members regarding quality of care and the acuity of the patients being admitted to your respective facilities. We provided specific analyses supporting our asks, and they agreed to substantial changes including moving from three levels to four. Please see below:

Level I $375

Level II $425

Level III $460

Level IV $600

I have attached the revised rate sheet and definitions. Please note that in the definitions, each level can be advanced to the next by providing some of the additional services listed in that definition. It is important to understand how this works, so your facility gets reimbursed appropriately. They have also approved a drug carve out. The only piece that is remaining is the outpatient fee schedule. We had proposed a percent of charges, and they will not agree to this. They are requiring this payment to be according to their AMFS fee schedule. They are going to send us that fee schedule, and we ill counter propose a percentage of that fee schedule.

In addition to the rates, they also agreed to the majority of our language requests including the following:

• They agreed to limited audits (no more than 2 per year consisting of no more than 10% of the facility’s claims for dates of service within a one year time period)
• They increased the billing timeframe to 180 days
• They agreed to remove language allowing for pre-payment audits – we don’t want claims held up for payment; audits will be only post payment
• They removed the language stating that both parties’ legal counsels have reviewed and agree that both have had a hand in writing it. This clause was problematic. The only way we could agree to this would be for both parties’ legal counsels to actually meet, go through each provision and agree on each. It’s Aetna’s way of removing any possible legal issue that could arise. We have been able to get this section removed in other Aetna agreements we have negotiated. I sent our contractor examples of where Aetna has agreed to removing this language.

Also, as we previously noted, Aetna is moving forward with an OASN agreement with an attachment of the list of providers. Right now, they are agreeing to accept the providers that responded to the surveys, although they are looking at the facilities with below a three star rating to see if they can justify the inclusion based on the other information we have provided for each facility. They accepted applications for all facilities.

We are looking at a January 1st start date. Because we have some facilities that are contracted with MNS through the end of the year, in order to get a clean start date, January 1st is a must.

Please note that Aetna is very impressed with OASN, which is reflected in this negotiation, and they do plan on moving to a P4P in the future. This agreement has a two year term and we will re-engage to renegotiate in 2019 which give us time to collect meaningful data on Aetna members.

I will forward the Aetna contract to the contracting committee for review and recommendations. We will then forward to the OASN members that submitted their information to be included in this contract (we only had two facilities that did not respond) for a final vote. We will then let Aetna know if any of the facilities are opting out of the agreement. Once they make the final changes to the document, we will forward to Jim Formal for signature.

MMO

MMO has once again pulled back on the OASN contract, and has shared that their new VP of contracting has closed their network (again) until they have a chance to review their current network.

MMO has offered contracts, and then pulled them on three separate occasions. This is not working in good faith, and something I have not experienced in my years of contracting. I actually know the new VP, so I did reach out to him. We are meeting to discuss on Wednesday. I have reminded him of thousands of MMO customers that are working within the OASN facilities as well as their families. I believe we really need to put pressure on them, and utilize the leverage we have. I will keep everyone posted.

MMO has agreed to full Medicare reimbursement for the Medicare contract. We are continuing to work with them on the commercial, although this will be very low volume. Once we have the final agreement, we will send to the contracting committee to review.

We have started the process for the OASN contract with MMO. Again, MMO has agreed to negotiate a contract inclusive of the Medicare product for all 4 and 5 star facilities. They will not terminate any existing contracts with facilities that have lower star ratings. The new OASN agreement will also include home health and hospice.

We have completed the spreadsheet for the creation of the contract and will forward that along with the proposal to MMO later today.

Good news. MMO has agreed to work with us on an OASN network agreement including the Medicare product. We will be negotiating a new agreement for OASN members. Now, MMO will only include 4 and 5 star facilities in this new network agreement; however, they will not terminate any contracts for facilities that are currently contracted that are 3 stars or less. We argued the use of the star rating system and have tried to get them to move to the OASN metrics and outcomes, but they are stating they are not yet ready. They did share that they will be narrowing their network in the future, so facilities have time to improve their ratings. We understand that the star ratings are going to be frozen for a period of time, and I did share that with MMO as well. This will be an issue for facilities making their way up in regard to their rating, and MMO understands this. We can share the survey information with them showing any improvement being made at that time in order for them to consider.

To get the new contract started, we will need to complete MMO’s spreadsheet for all facilities that will be included. We will also be including home care and hospice services. We will not need to recredential any facility, unless they have not had a contract with MMO in the past.

Buckeye

Buckeye is finalizing the shared savings agreement and gold card documents. We are to have them in hand this week. We will review and provide a summary of the actual contract. The start date will be 1/1/18.

Also, as you know, Buckeye has terminated its contract with Optum. Some of you may have already received documentation from Optum explaining the transition. For those that have received this document, can you please forward a copy to our attention? We had asked Optum to send, but they said that until all of the hard copy documents are sent to the facilities, they cannot send one to us electronically.

Please remember that Buckeye has requested a list of facilities who wish to provide care management services within your respective facilities and be paid for the service. To date, we have very few facilities that have shared interest. If you do wish to be part of these discussions, please let me know ASAP.

Buckeye let us know today that they are going to include all OASN facilities in the duals regions to be in the gold card program. This will mean that authorizations will not be required, but they will have an audit process initially to ensure medical necessity is being met. This will be reduced over time for those facilities that have positive audits.

We are meeting with Buckeye on Monday to discuss our final steps. Once this contract is finalized, it will go back out to the contracting committee for approval, and then on to Jim for signature. We will then be holding webinars to go through the contract along with Buckeye. We will get this information out to the facilities participating as soon as everything is finalized.

We are getting close to finalizing the P4P with Buckeye. During our last meeting, they provided the attached updated proposed document. They have also included an incentive Pool comprised of $100,000 baseline and incremental PMPY payment per member admitted to an OASN facility. This was an addition to the already proposed P4P. This is upside only.

They are continuing to work on our requests for the Gold Carding process. We have our weekly meeting scheduled for tomorrow to discuss the final pieces.

We also met with Buckeye to further our discussions on the P4P. I have attached the most recent language. We continue meeting with Buckeye on a weekly basis, and will have the contracting committee continue to provide feedback in addition to Arlene and Vicky on the quality side.

Per our meeting with Buckeye earlier today, they provided us with a draft of the scorecard. Please see attached. They pulled OASN data on the facilities in their MyCare region. We are confirming that the data is correct as the Pressure Ulcer percentage seems high. We believe the rest are correct, but will confirm and Buckeye is doing so on their end as well.

Buckeye is fine tuning the tiering and will have numbers for us at the beginning of next week. We have our standing meeting with them again next Wednesday, so we will go through the numbers with them at that time, and then follow up with the contracting and quality committees.

We met with Pam, Vicky and Arlene to discuss from the quality perspective and did go back to Buckeye with several asks. Buckeye reviewed our proposal, and provided us with an updated P4P last week that included the following:

• Change the benchmarks to be based on state and national averages
• They will do the analysis based on the aggregate, so the OASN facilities can capitalize on this opportunity and not just the large ones.
• They agreed to do a tiered approach in regard to meeting the metrics:
• There are 7 measures
• 0-2 met = 0% of surplus
• 3-4 met = 25% of surplus
• 5-7 met = 50% of surplus

In addition, they are still working on an update for the gold card status. They are to have that for us this week. Also, they are still pushing the care management component. So, if there are any facilities in Buckeye’s regions that have not responded that they wish to do the care management for Buckeye within your respective facilities, please let me know.

Anthem

We have been in receipt of an Amendment for some OASN facilities in the Cleveland market to be part of a product that includes Anthem and the Cleveland Clinic. When Anthem comes out with new products, they keep the pricing the same. We have pushed back on Anthem requesting rate increases, since the rates we have been working with are over two years old, and for many they are even older. Anthem did respond and said that they have no plans to provide increases. Per Cheryl Hattorf, the SNF contractor, “It’s a robust network and the market is still supporting the standard and value program rates. If the value program survey is done again that would be the only opportunity but there aren’t any plans for this year or next year.”

This is problematic as again, facilities continue to provide services at the same rates, so here is no incentive for Anthem to increase. It is important for the facilities to be able to capitalize on the different levels of care, and get their patients approved at level 3.

Anthem has reached out to let us know that they will be holding inservices with their UM and care management personnel. We will provide details as soon as they are received.

We have submitted applications/surveys on behalf of the OASN facilities that are not currently contracted with Anthem that wish to be. We have started receiving contract documents, and have sent those along with the summaries to those facilities. We have also provided HealthAgree information for those facilities that also wanted to be part of HealthAgree’s care management program to obtain authorizations for level 3.

We have started receiving fully executed documents. They are coming slowly, but are in the process.

In addition, we are continuing discussions with Anthem government relations in regard to potential P4P.

We have been working with Anthem on new provider requests. We received word from them today that they will consider additional providers if they are three star or higher. Now, they have also approved a new facility that does not yet have a star rating. We are confirming with Anthem that new facilities will be considered without a star rating and that both commercial and Medicare will be part of the agreement. We will keep everyone posted as this information comes in.

UHC

We did meet with UHC/Optum to discuss their potential shared savings. UHC is actually proposing a shared savings based on money that is saved on patient stays, for long term patients. This would be money that would be shared if patients are moved from long term care into assisted living or home with supports, or if the patients are potentially moved from the facilities for different outings, etc. and savings occur.