Commonwealth Medicine’s Center for Health Care Financing (CHCF) will be putting its experts to work on behalf of the state of California to improve health care access for individuals and maximize savings for the state. The work is part of a two-year, $7.3 million pay-for-performance contract with the California Department of Health Services that began in October 2010. Throughout the country, millions of people rely on Medicaid and Medicare to obtain health care coverage and benefits [see sidebar for an explanation of the difference]. When individuals qualify for both programs, they have the potential to receive more comprehensive coverage, and the states in which they live have an opportunity to save on expenditures for services administered. Enhancing benefits for members and maximizing savings for states often requires increased Medicare coverage. Attaining that coverage involves skillful coordination with the Social Security Administration (SSA) and the Centers for Medicare and Medicaid Services (CMS), which often necessitates resources that states may not have. Having cultivated unique expertise in working with SSA and CMS on behalf of states, CHCF was contracted by the California Department of Health Services to implement two techniques to increase Medicare coverage and savings in that state. The first is an enhanced Medicare identification project that will work within current California processes to identify California Medicaid members who are also eligible for Medicare. The second is a quality control review project that will audit the federal bills issued to California for payment of Medicare premiums, known as Medicare Buy-In. “The application of these techniques will benefit both dual-eligible individuals in California and the state itself,” said CHCF Director Marc Thibodeau, JD. “Medicare identification will enable individuals to receive more increased and more comprehensive coverage, resulting in better access to better care in more extensive networks, and will afford the state opportunities to recover some of its past expenditures. The project will also enable the state to bill Medicare before Medicaid is asked to make a payment, which will provide future cost savings.”
According to Thibodeau, California’s current contingent of 1.1 million dual-eligible individuals is the largest in the country (five times the number in Massachusetts), and he estimates that the identification project may result in approximately $100 million in cost avoidance savings for the state. “The quality control review portion of the contract will likely assist the state in achieving a 3 to 5 percent credit on its buy-in bill activities,” Thibodeau added. CHCF’s data analysis expertise is well known throughout the country. In 2009, a similar quality review project identified federal payment inaccuracies totaling more than $250 million, which were credited to 46 states and the District of Columbia. CHCF has also been providing enhanced Medicare identification and Medicare Buy-In billing analysis expertise to the Commonwealth of Pennsylvania since early 2009. “I’m not aware of another group in the country that has developed these types of data analysis techniques, not to mention a comprehensive understanding of the dual eligible population and how the SSA and CMS work,” said Thibodeau. “CHCF is uniquely positioned to make sure that people are getting the proper and appropriate level of health care benefits, and that states are able to more accurately monitor and control expenditures in support of those benefits.” About the Center for Health Care Financing Commonwealth Medicine’s Center for Health Care Financing (CHCF) has extensive knowledge of government financing structures that is used to identify savings initiatives for the benefit of its non-profit and public agency clients. CHCF consultants, who are well-versed in third party liability, program integrity, school-based and federal revenue claiming, analyze human service entitlement programs to identify areas eligible for enhanced or supplemental federal reimbursement. For more information, visit www.umassmed.edu/commed/financing. About Commonwealth Medicine Commonwealth Medicine (CWM) is the public, nonprofit health care consulting and service organization founded by UMass Medical School. Government agencies, nonprofits and managed care organizations benefit from CWM’s expertise in clinical service delivery, health care financing strategies, policy management and quality improvement. CWM programs have helped Massachusetts—and many other state, international and local health care agencies—to increase the value of health care expenditures while improving access and delivery of care to at-risk and uninsured populations. Commonwealth Medicine programs were developed, in part, as a way for UMMS faculty and staff to have a direct and profound impact on the communities of Massachusetts, and now provide critical opportunities for UMMS faculty and students to serve the community.
For more information, visit www.umassmed.edu/commed.