ACCOUNTS RECEIVABLE THE EFFECTS OF ACA ON WYOMING SELF-PAY Solutions for: THE EFFECTS OF ACA ON WYOMING SELF-PAY ACCOUNTS RECEIVABLE March 15, 2018 Wyoming Healthcare Financial Management Association Presented By: Karie Snyder, VP of Operations & Compliance Kris Brumley, VP of Customer Service Excellence Kory Eller, Recovery Services

The Affordable Care Act Affordable Healthcare Coverage Requires most US citizens to gain coverage or face tax implications Established insurance exchanges for affordable care plans Provided cost-sharing tax credits to lower income people Medicaid Expansion Dropped income requirements to 133% of Federal Poverty Level Expanded coverage to all non-Medicare eligible individuals under age 65 Supreme Court changed enforcement to allow States the option to accept or reject Extended CHIP income eligibility through 2019 Expanded Dependent Coverage (26) Administrative Simplification (EFT, Remits, Auths..etc..) Reduced DSH payments National Quality Strategy - Value Based Payments and incentives

Expected Impacts of ACA on Accounts Receivable Increase Medicaid Increase Self-Pay - Balance After Insurance Increase Commercial and Managed Care coverage Reduce Charity Care

Actual Impact by Payer – Ascension Health

Actual Impacts of ACA in Wyoming Self-Pay Difficult to find! Healthcare Providers queried did not see a marked impact up or down on % of self-pay AR. What is your experience?

Wyoming Stats Wyoming is the least populated and least densely populated State Wyoming has the highest rate of uninsured residents. Since the ACA started Wyoming shows the 4th smallest reduction of uninsured care. Coverage gap is higher for residents making <100% of the FPL but not meeting Medicaid guidelines.

Other Impacts of ACA in Wyoming Medicaid enrollment decreased 8.4% since ACA Uninsured rate 11.5% (down from 13.4%) 22,000 individuals insured through the exchange plans in 2017 Wyoming Care Quality Data ranked against other states: *Sources: BallotPedia; US News and World Report; U.S. Census Data; Kff.org

ACA and Cost of Care Medicaid Expansion states noted 40.1% decrease in Charity care costs compared to 6.2% in non-expansion states. The net cost of caring for low income patients decreased among hospitals in expansion states, while these costs increased among hospitals in non-expansion states. Lower Medicare payment growth as part of ACA. No impactful cost information noted from commercial coverage provided by the healthcare insurance exchanges from initial reviews. *SOURCES: Kaiser Family Foundation- Kaiser Health Tracking Poll – February 2018. kff.org; Kellogg Insight northwestern.edu – Craig Garthwaite Associate Professor of Strategy at the Kellogg School; Becker Healthcare Review

Affordable Care Act - Growing Pains Initial exchange sign-up issues Increasing Coverage Premiums – double digit increases in many states. Single digits for WY residents Payers dropping out (Aetna, Humana, United Healthcare) some exchanges only have 1 EHB provider (no more choice) Only 1 payer offering EHB (essential health benefit) program in Wyoming.

Wyoming Economic Factors affecting Healthcare Wyoming still recovering from economic downturn in 2016. Although some jobs added in 2017. 2 years of declining population linked to job losses in Coal and Oil/Gas (which accounts for 70% of WY Revenue) 5,600 residents left between 7/16 and 7/17. Many younger residents left the state for jobs while older residents remained leaving 65+ aged residents as a higher % of the population. While economy is slowly rebounding and jobs are starting to come back in key industries there is concern with long term viability of Coal industry. More WY coal customers are converting to other more affordable and renewable sources of energy. *Source: Wyoming Tribune Eagle 12/29/17 “Wyo’s Economy still feeling effects of downturn, population loss”

What does that mean for WY Healthcare? Cost savings sought through affiliations among providers. Physician affiliations are key to promoting physician availability (especially in rural areas) along with improving quality outcomes Increase in ACO’s anticipated to pull together all aspects of care Successful implementation and meaningful use of EHR is critical to receiving incentive payments. Revenue Cycle Improvement opportunities *SOURCES: Wyoming Hospital Association;

Revenue Cycle Improvement Strategies Examine workflows to identify inefficiencies Be diligent in working denials promptly– look for patterns Watch and ensure strong clinical documentation Review and offer creative financing programs for patients. (loans/financing alternatives) Use analytics to identify propensity to pay along with other key demographic data to stratify outreach efforts Ensure patient-friendly communication: email – text – phone Create solid easy-to-understand statements to clearly outline summary of amount due (less questions – less delay to payment) Have easy and well-advertised payment options for patients Ensure your financial agreements have TCPA “consent” language to allow for contact!

Health Sharing Programs and Medical Cost Sharing Health Sharing Ministries: Liberty Healthshare Christian Healthcare Ministries Samaritan Ministries Medi-Share Medical Health/Cost Sharing Ministries – these are not health care or health insurance but provide an affordable, faith-based way to plan for unforeseen medical expenses.  These are not a “cheap insurance program”.  These are a completely different concept all together!  Simply put – these are created by a group of like-minded individuals that agree to come together and help each other with payment for medical expenses. 

HCSM’s Health Care Sharing Ministries are not insurance, and the rules are different:  There are options for both individuals and families No network requirements and you can go to any facility or doctor Once enrolled, the patient is issued a membership card It will be processed the same way as insurance. If the provider doesn’t accept the membership, the health sharing program pays cash   Programs are exempt from the requirements of the ACA health insurance mandate Members pay a monthly share amount and cover annual personal responsibility. (deductible) Medical expenses are shared among the group.   Restrictions:  Faith-based ministries use different guidelines for smoking or certain pre-existing health or lifestyle related conditions.  Could result in a decline of membership or payment Pre-existing health conditions might be accepted but may be handled differently such as phasing in, etc.  Some pre-existing conditions may also never be shareable under the program.  Just ask!  

Future of ACA? Medicaid Expansion? Split issue.. 56 % say they think their state should expand Medicaid to cover more low-income uninsured people. 37% say their state should keep Medicaid as it is today. Multiple legal challenges: Recent polls show the following healthcare priorities on their agenda:

Future of ACA? DSH Cuts (starting in 2018) Affects on facilities? Consumer uncertainty about the future Funding for ACA Repeal of Individual mandate (what will happen this November)? Will issue be raised again in Congress? How will the 2018 elections affect ACA? What about choice of coverage? Insurance companies pulling out of exchange Cost of coverage continuing to rise… Wyoming subsidy payments have increased for 2018 for insurance. What will happen in 2019? Increased self-pay population as more opt-out of insurance?

Questions?