Consulting Administration Brokerage Communications Compliance - - PowerPoint PPT Presentation

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Mar 30, 2023 165 likes •384 views

Consulting Administration Brokerage Communications Compliance About our Speaker Scott Mayer Director of Data Analytics, CrawfordAdvisors, LLC Scott focuses on helping employer groups use the vast amount of healthcare data at

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Consulting │ Administration │ Brokerage │ Communications │ Compliance

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About our Speaker

CrawfordAdvisors, LLC

Scott Mayer Director of Data Analytics, CrawfordAdvisors, LLC

Scott focuses on helping employer groups use the vast amount of healthcare data at their disposal to identify and stratify the risk within their employee population, and develop programs and strategies aimed at controlling and containing said risk. Scott is very active in the healthcare community, having served on numerous boards and committees such as:

Executive board of the Baltimore Association of Health Underwriters
The Navigator Advisory Committee for the Maryland Health Connection,
The NAIFA-MAHU Joint Legislative Committee.

His legislative efforts have garnered awards and recognition at both the state and national

level. Scott holds a degree in math and physics from Cornell University, and loves the

challenges of working with big data sets to develop meaningful analytics, predictive

utcomes, and statistical projections for his clients.

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Not all Services are Created Equal

CrawfordAdvisors, LLC

Billed Amount Allowed Amount Source Procedure Code Source Procedure Description Provider ID Place of Service Description $ 1,068.00 $ 826.41 80061 Lipid Profile 1205859766 Outpatient Hospital $ 1,008.98 $ 38.08 80061 Lipid Profile 200248060 Outpatient Hospital $ 1,008.98 $ 38.08 80061 Lipid Profile 200248060 Outpatient Hospital $ 6.55 $ 6.55 80061 Lipid Profile 1134165970 Independent Laboratory $ 6.55 $ 6.55 80061 Lipid Profile 1134165970 Independent Laboratory $ 6.55 $ 6.55 80061 Lipid Profile 1205854817 Independent Laboratory $ 6.55 $ 6.55 80061 Lipid Profile 1205854817 Independent Laboratory $ 6.55 $ 6.55 80061 Lipid Profile 1134165970 Independent Laboratory

Basic Services: Bloodwork (Lipid Profile)

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Not all Services are Created Equal

CrawfordAdvisors, LLC

Basic Services: Chest X-Ray

Billed Amount Allowed Amount Source Procedure Code Source Procedure Description Provider ID Place of Service Description $ 1,754.00 $ 205.12 71020 Chest X-Ray-71020 1073516183 Outpatient Hospital $ 1,531.12 $ 268.74 71020 Chest X-Ray-71020 1669427258 Emergency Room Hospital $ 1,436.93 $ 23.02 71020 Chest X-Ray-71020 1063470763 Outpatient Hospital $ 21.22 $ 21.22 71020 Chest X-Ray-71020 1649220443 Office $ 21.15 $ 21.15 71020 Chest X-Ray-71020 1609865708 Office $ 21.00 $ 13.00 71020 Chest X-Ray-71020 381893379 Urgent Care Facility $ 20.99 $ 20.99 71020 Chest X-Ray-71020 1669405700 Office $ 20.33 $ 20.33 71020 Chest X-Ray-71020 1609865708 Office

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Not all Services are Created Equal

CrawfordAdvisors, LLC

Basic Services: CT Scan (Full Body)

$ 203.00 $ 199.00 R352 CT Scan - Body Scan 520591656JOHNSHOPKIN Outpatient Hospital $ 200.00 $ 196.00 R352 CT Scan - Body Scan 526049658GREATERBALT Emergency Room Hospital $ 198.00 $ 196.00 R352 CT Scan - Body Scan 520591531WESTERNMARY Emergency Room Hospital $ 198.00 $ 196.00 R352 CT Scan - Body Scan 520610538 Emergency Room Hospital $ 196.00 $ 192.00 R352 CT Scan - Body Scan 520591612FREDERICKME Emergency Room Hospital Billed Amount Allowed Amount Source Procedure Code Source Procedure Description Provider ID Place of Service Description $ 21,445.00 $ 10,888.00 R352 CT Scan - Body Scan 582032904KENNESTONEH Inpatient Hospital $ 17,419.00 $ 9,656.00 R352 CT Scan - Body Scan 880213754RENOWNREGIO Inpatient Hospital $ 17,419.00 $ 16,281.00 R352 CT Scan - Body Scan 880213754RENOWNREGIO Inpatient Hospital

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Not all Services are Created Equal

CrawfordAdvisors, LLC

Basic Services: MRI Brain (with & w/o dye)

Billed Amount Allowed Amount Source Procedure Code Source Procedure Description Provider ID Place of Service Description $ 4,960.00 $ 1,287.00 70553 Mri Brain W/O&w Dye 6490915THOMASJEFFERS Outpatient Hospital $ 4,816.00 $ 1,287.00 70553 Mri Brain W/O&w Dye 6490915THOMASJEFFERS Outpatient Hospital $ 4,810.00 $ 979.00 70553 Mri Brain W/O&w Dye 1386749893 Outpatient Hospital $ 556.00 $ 149.00 70553 Mri Brain W/O&w Dye 541098455FOUSTROBERT Office $ 551.00 $ 551.00 70553 Mri Brain W/O&w Dye 201749446MEDSOLUTION Office $ 365.00 $ 216.00 70553 Mri Brain W/O&w Dye 421066542RADIOLOGIST Office $ 365.00 $ 216.00 70553 Mri Brain W/O&w Dye 421066542RADIOLOGIST Office $ 334.00 $ 216.00 70553 Mri Brain W/O&w Dye 421009288MASONCITYCL Office

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Unreal! What can we do about it?

CrawfordAdvisors, LLC

Tools at your disposal: Plan Design

Facility Fees
Surcharges
Tiered Charges
Reference Based Pricing

Network

Narrow Networks
Exclusion from Benefits

Consumerism

Deductibles/Reference Based Pricing
Apps/Websites
Advocacy Vendors
Bundled Payments

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Reference Based Pricing

CrawfordAdvisors, LLC

Set the Benchmark: MRI Example Determine a Median “Reference Price”

Reimburse a certain percentage up to the reference price
Charges over the price are member’s responsibility
Can include opportunities for shared savings

Low Cost ($149) High Cost ($1300)

Reference Price ($600)

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Narrow/Tiered Networks

CrawfordAdvisors, LLC

Drive Efficient Utilization and Reduce Costs

Benefit Low Cost/Hi Quality Provider Regular In- Network Provider Out-of-Network Provider

MRI/CT Scan

No Deductible Plan pays 100% $2000 Deductible Plan pays 90% $4000 Deductible Plan pays 70%

IP Surgery

No Deductible Plan pays 90% $2000 Deductible Plan pays 80% $4000 Deductible Plan pays 60%

OP Surgery

No Deductible Plan pays 100% $2000 Deductible Plan pays 90% $4000 Deductible Plan pays 70%

Maternity

No Deductible Plan pays 100% $2000 Deductible Plan pays 90% $4000 Deductible Plan pays 60%

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Narrow/Tiered Networks

CrawfordAdvisors, LLC

“Centers of Excellence” – Heart Attack Example

https://www.medicare.gov/hospitalcompare/search.html

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Narrow/Tiered Networks

CrawfordAdvisors, LLC

“Centers of Excellence” – Hip/Knee Replacements

https://www.medicare.gov/hospitalcompare/search.html

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Consumer Tools/Websites/Apps

CrawfordAdvisors, LLC

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Non-PBM Pharmacy

CrawfordAdvisors, LLC

The Large Costs Lurking in the Shadows…

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What are J-Codes?

CrawfordAdvisors, LLC

HCPCS Codes are a Subset of the CPT Codes

Healthcare Common Procedure Coding System

A-codes (example: A0021): Transportation, Medical & Surgical Supplies, Miscellaneous & Experimental B-codes (example: B4034): Enteral and Parenteral Therapy C-codes (example: C1300): Temporary Hospital Outpatient Prospective Payment System D-codes: Dental Procedures E-codes (example: E0100): Durable Medical Equipment G-codes (example: G0008): Temporary Procedures & Professional Services H-codes (example: H0001): Rehabilitative Services J-codes (example: J0120): Drugs Administered Other Than Oral Method, Chemotherapy Drugs K-codes (example: K0001): Temporary Codes for Durable Medical Equipment Regional Carriers L-codes (example: L0112): Orthotic/Prosthetic Procedures M-codes (example: M0064): Medical Services P-codes (example: P2028): Pathology and Laboratory Q-codes (example: Q0035): Temporary Codes R-codes (example: R0070): Diagnostic Radiology Services S-codes (example: S0012): Private Payer Codes T-codes (example: T1000): State Medicaid Agency Codes V-codes (example: V2020): Vision/Hearing Services

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J-Codes are Big Business

CrawfordAdvisors, LLC

HCPCS Codes are a Subset of the CPT Codes

26% 50% 3% 6% 15%

Why Hospitals are Purchasing Practices

Lower Physician Reimbursements Expansion of Infusions Centers Access to Referred Infusion Patients Other Don't Know

Source: Magellan Rx

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What are J-Codes?

CrawfordAdvisors, LLC

Are They Run Through PBM, or Medical Plan?

NDC HCPCS HCPCS Description NDC Label 00944-2700-02 J1569 INJECTION, IMMUNE GLOBULIN, (GAMMAGARD LIQUID), NON-LYOPHILIZED,(E.G. LIQUID), 500 MG GAMMAGARD LIQUID (PF,LATEX-FREE) 100 MG/ML

Hospital Medical Plan Discount of Billed Charge

Specialty Pharmacy PBM AWP Minus

Provider Medical Plan ASP Plus/AWP Minus

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Not all Services are Created Equal

CrawfordAdvisors, LLC

J9035 Bevacizumab Injection

Plan Paid Amount Source Procedure Code Source Procedure Description Place of Service Description $ 55,555.54 J9035 Bevacizumab Injection Outpatient Hospital $ 55,555.54 J9035 Bevacizumab Injection Outpatient Hospital $ 55,202.69 J9035 Bevacizumab Injection Outpatient Hospital $ 37,426.08 J9035 Bevacizumab Injection Outpatient Hospital $ 32,949.67 J9035 Bevacizumab Injection Outpatient Hospital $ 2,913.20 J9035 Bevacizumab Injection Office $ 2,913.20 J9035 Bevacizumab Injection Office $ 2,913.20 J9035 Bevacizumab Injection Office $ 2,722.00 J9035 Bevacizumab Injection Office $ 2,722.00 J9035 Bevacizumab Injection Office $ 2,722.00 J9035 Bevacizumab Injection Office

*Medicare Reimbursement Rate for 10mg = $69.60

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Not all Services are Created Equal

CrawfordAdvisors, LLC

J2505 Pegfilgrastim Injection

Plan Paid Amount Source Procedure Code Source Procedure Description Place of Service Description $ 25,162.89 J2505 Injection, Pegfilgrastim, 6 Mg Outpatient Hospital $ 16,833.00 J2505 Injection, Pegfilgrastim, 6 Mg Outpatient Hospital $ 15,826.35 J2505 Injection, Pegfilgrastim, 6 Mg Outpatient Hospital $ 15,762.89 J2505 Injection, Pegfilgrastim, 6 Mg Outpatient Hospital $ 15,630.74 J2505 Injection, Pegfilgrastim, 6 Mg Outpatient Hospital $ 699.09 J2505 Injection, Pegfilgrastim, 6 Mg Office $ 699.09 J2505 Injection, Pegfilgrastim, 6 Mg Office $ 673.76 J2505 Injection, Pegfilgrastim, 6 Mg Office $ 673.76 J2505 Injection, Pegfilgrastim, 6 Mg Office $ 673.76 J2505 Injection, Pegfilgrastim, 6 Mg Office $ 673.76 J2505 Injection, Pegfilgrastim, 6 Mg Office

*Medicare Reimbursement Rate for 6mg = $3,772.79

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Medical vs. Specialty Pharmacy

CrawfordAdvisors, LLC

J1459 IVIG Privigen 500mg Injection

*Medicare Reimbursement Rate for 500mg x 200 units = $7,610

Hospital Provider Medical Plan Charge 200 Units Twice per Month Specialty Rx Once a Month Sent to Clinic Administered Onsite

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CrawfordAdvisors, LLC

Questions?