DRAFT 25 Eliminating the 90 Day Waiver Proposal Questions from Rick: 1.What are other payers doing? 2.What are other Medicaid agencies doing?

Background MassHealth deadline to submit a claim within 90 days by State Law. Federal Regulation 42 CFR (c) sets a deadline date to submit claims at 12 months. MassHealth should consider adopting the Federal claim submission deadline. New York has a 90 day deadline Blue Cross….. Medicare…… 2

Overview Providers must submit claims 90 days after date of service Provider who miss this deadline may apply for a 90 day waiver MassHealth Administrative cost of 90 Day Waiver = $400K Maximum cost to eliminate Edit 850 (Billing deadline Exceeded) = $2.7M Cost to Eliminate Edit & Waiver $2.7M - $400K = $2.3M Cost to Eliminate Waiver Only $580K - $400K = $185K 3

90 Day Waiver Lifecycle Current Provider Renders Service Provider Submits Claim & gets denied Claim Denies for 90 Day Provider Submits 90 Day Request 70% Manually Approved 30 % Manually Denied 15% Ultimately Denied 15% Eventually Approved Provider resubmits to correct errors 90 Days 12 Months Provider has fatal errors or does not correct errors within 90 days* Provider Submits Claim after 90 days Denied for other edit Paid Day 0 * Denial related to provider or member ID 4

Top Approval and Denial Reasons for a 90 Day Waiver Request Approval Reasons: 1. Member did not inform the provider they had MassHealth 2. Member ID number changed 3. Member eligibility retroactively backdated 4. Provider ID changed Denial* Reasons: 1. Dates of service and names on claim do not match waiver request 2. Insufficient documentation 3. No eligibility verifications provided *These administrative errors ultimately end up getting corrected and the majority of claims get paid. 5

Monthly Waiver Numbers Of the 18,350 claims that deny monthly for the billing deadline exceeded edit, an average of 5,900 claims ( 32%) are submitted monthly for 90 day waivers (70K for FY15) 70% of the 5,900 are approved after manual review Half of the remaining 30% are eventually paid as a result of provider re-submission for corrections within 1 year. More ultimately pay as a result of appeals. 6 Update Numbers

Monthly Waiver Numbers 18K Over 90 Days 12,100 No Waiver 8,350 Pay 3,750 Deny 5,900 Apply for Waiver 4,130 Pay 1,770 Deny 885 Pay 885 Deny 7 Update Numbers

Options Eliminate the 90 Day Deadline (shut off edit, regulation change) Leave the edit on, but streamline the process by approving all Waiver requests (1 FTE) Extend the deadline 6 – 9 Months (2 - 3FTE, regulation change) 8

Benefit of Adopting the Federal Policy Improve provider customer experience by simplifying claim submission process Claims could pay faster by eliminating the 30 day time frame for processing a waiver request Reallocation of resources, including 4 FTE’s working 7,500 hours annually on 90 day waiver claims Maximus 2 employees = 2FTEs MassHealth 6 employees (prorated) = 2 FTEs* *MassHealth staff would be reallocated to Appeals Unit 9

Billing Deadline Exceeded Claims Jan. 1, 2014 – January 31, ,350 Claims, representing $1M, denied for Edit 850 Billing Deadline Exceeded. 13,750 Claims, representing $775K eventually paid (75% of Claims). Potential annual impact of eliminating the Edit: $225K x 12 = $2.7M $2.7 - $400K = $2.3M Add in the # of claims submitted ea. mo.

Behind the Numbers - Administrative Denied Waiver Cost (48,675 x 12) $580K Annual Admin Cost (4 FTE)-$400K Potential Annual Loss $180K 11 Monthly 90 Day Requests Monthly Approved Monthly Denied Denied & Paid within 1 Year Monthly Impact $ $324,500$227,150$97,350$48,675 Avg Cost per 90 Day Claim

Without 90 Day Deadline Proposed Provider Renders Service Provider Submits Claim Denied Approved 12 Months Denied Approved Provider resubmits to correct errors multiple times if necessary Day Months6 Months