Ohio Aging Services NetworkContracting Update

10/9/17

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

Highlights:

AetnaThe 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:

o 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)

o They increased the billing timeframe to 180 dayso They agreed to remove language allowing for pre-payment audits – we don’t want claims held up for payment;

audits will be only post paymento 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.

BuckeyeBuckeye 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:

o There are 7 measureso 0-2 met = 0% of surpluso 3-4 met = 25% of surpluso 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.

AnthemWe 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.

UHCWe 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.

We did share that we have had discussions with other payors regarding a potential increased rate for assisted living with supports, and they were open to this; however, UHC has been slow to actually put anything meaningful on the table.

So, they are to have white paper to us by next week including details for this potential opportunity. They are also still working on their measures for the short term side. We again pushed back on this, and requested that all facilities be included.

We are meeting with UHC next Tuesday to further discuss a potential P4P that is more aggressive than the pilot that Optum has talked with us about. UHC is also addressing the issue of facilities within OASN that have not been able to become contracted.

Met with Jeff Corzine yesterday to discuss several issues. Optum is still lagging behind the other payors in regard to increases and P4P. They are interested in the rounding program, but did ask to reschedule the meeting to discuss the program at the last minute. Jeff shared that Optum is behind and that we should engage Jackie and possibly Tim to help get things moving. Jeff was very committed to OASN, and does not like the fact that they are not moving forward on the initiatives we put forth months ago. With this said, I did reach out to Jackie to schedule a meeting.

UHC is supposed to be scheduling a follow up to continue P4P discussions. We are currently working with UHC directly on a shared savings for the FQHC network. We are going to see if the UHC folks can engage with OASN to do a shared savings agreement. If they cannot, we will share the program specifics with Optum to see if we can get them to move in this direction, rather than a pilot with a few facilities and a few measures.

We had a call with UHC today as they wanted to discuss their P4P. We were disappointed as they had no real detail except that they have narrowed their measures to five:

All cause admissions Flu Vaccines Antipsychotic drugs Falls with major injury UTI

They are wanting to roll out a pilot for those facilities with higher opt in numbers, so again, we do not see this as a true P4P. We are trying to push them to finalize the program, and implement so that OASN participates in the aggregate. This will give them the numbers they are looking for, and allows all facilities to participate and earn extra dollars. They are looking into this, and do want to continue our discussion in two weeks.

In addition, we have asked for facilities to respond if they received letters from UHC about adding their AL services to the network, even though there is no agreement for the SNF. Our contacts wanted copies of those letters, so if you could provide those to us, the contractors were going to get involved to see if they could also facilitate SNF agreements for those AL providers.

We met with UHC today. The meeting had a much better agenda than in the past. They are finalizing their model for P, and will have something for our review in the next one to two weeks. They are starting with MyCare, but do have plans to expand their P4P into the Medicare market, but did not have a timeframe for this. We did discuss the fact that there are many facilities with lower volume, so we proposed the P4P be tracked and calculated in the aggregate. They were very receptive to this.

UHC did state that they will be narrowing their network at some point, because they are so saturated. They will be looking at the quality of the building, star rating, LOS, admissions to hospital and overall performance. We will be kept in the loop for this discussion.

In addition, we discussed the fact that UHC has been sending contracts to facilities that are not contracted with UHC to contract with their AL or home care services. We pushed back to UHC on this, because they are cherry picking the service lines, when the facilities wish to be contracted for the SNF as well as the other services. Lisa Myers asked that I send her a list of the facilities that received this letter to see if there is something she can do on the SNF side. So, if you have received a letter from UHC regarding your AL or home care services for the MLTSS, please let me know, so I can add your facility to the list, if you are not already contracted with UHC.

MolinaThe P4P was approved by the OASN facilities. The LOA was signed by Jim Formal and returned to Molina. The start date was 6/1/17. Molina is now working on the marketing document to send to the hospitals/referral sources that will identify OASN as a preferred network for Molina referrals.

CareSource

We are continuing very slow progress regarding CareSource issues. We do have a meeting scheduled for Thursday to see where they are in the system update for all OASN facilities. They have confirmed that all facilities that had checks being sent either to us, or to other providers have been corrected in their system and payments are being issued. Please let us know if you are a provider that was affected by this, and if you do not see payment within the next few weeks.

CareSource has finally engaged and is attempting correct all of the loading/payment issues. The most recent problem identified is that they have several providers loaded under OASN’s TIN. As they are attempting to correct the problems, they are creating new ones. Tiffany went through the spreadsheet with them, and provided correct information. They are to give us status this week.

In addition, there has been an extension of the CareSource/Cleveland Clinic contract. Since is spans past the time of open enrollment, it looks like the contract will stand.

Providers did not agree to issue termination with CareSource. We continue to have the same issues including checks being sent to our office. We do have a follow up meeting with their VP on Monday. CareSource lost another decision maker, and has terminated the Cleveland Clinic. Now, the Clinic has put out the attached publication to their customers. We are starting to see some major players finally push back on CareSource, and this should make a difference.

CareSource issues are continuing. They are attempting to resolve some, but seem to be making the issues worse rather than better. They have not issued us a contact person to work with in person to resolve all issues as Steve Ringel and Dan Hounchell promised. We continue to get email follow up that has not been helpful.

At this time, we believe we need to discuss a strategy to move away from this agreement. It does not appear that CareSource has the desire nor the ability to resolve these issues. We did request feedback during the contracting call,

and Pam Richmond suggested that we do a survey vote to see how folks feel about issuing termination. We will discuss in the contracting committee and then bring a recommendation to the board on Thursday.

Also, CareSource had still shared that they wanted to do a P4P agreement, but have not provided any further detail on a contract. We don’t anticipate they will as they cannot get any of the issues resolved. We do not believe they would be able to effectively manage a P4P agreement.

We did have a meeting with Steve Ringel, Antoinette Geyer and Dan Hounchell from CareSource last Friday. We again addressed all of the issues we are still experiencing with them. Steve did commit to having a CareSource person assigned to us, and will have us meet with this person, in person to correct all of the system glitches. We are to have follow up this week.

In addition, they are still interested in pursing a P4P with OASN, and Steve also committed to this, and has promised follow up with details. We are awaiting this follow up.

Aetna Better HealthPer our contact at ABH, they are finalizing their P4P for us to review, but we still do not have anything definitive. They do have new software to track the data for P4P that we have discussed with them. It is potentially redundant for our facilities, so we are trying to determine if there is a way to get data from OASN to this new system without providers having to load manually. We will not agree to something that will result in additional work for the providers. We will be discussing with the quality chairs.

Medigold

This contract was signed and returned to MediGold two weeks ago. They did acknowledge receipt, and will be forwarding a fully executed document for our records. Once the contract is finalized on their end, we will be scheduling an inservice for all OASN facility staff that will be part of this contract. MediGold staff will be part of this inservice. Information will be forthcoming.

Final documents have been sent to the facilities that are part of the MediGold contract. We have not received notice that ones that have been notified do not wish to participate, so we will move forward and send to Jim Formal for signature.

We believe that we are in the finally stages with MediGold. They needed some updated credentialing documents this week, and everything has been sent. We will let everyone know once this is done.

Per Medigold, they are still credentialing. We are pushing them to get this completed, and we did receive follow up today that let us know they are working on it.

The contract was reviewed, and the changes agreed upon were captured. It is ready for signature; however, they are still credentialing the facilities and wanted us to hold on signing until everything is completed. We will have to amend to add the home care piece as we do not want to hold this contract up any longer.

GateWay

Contracting with Gateway will resume in October. The redline was submitted to Gateway, and the rate negotiation has begun. We will contract for the Medicare and include any other products as they roll out and the rates make sense.

SummaCare

SummaCare did respond that, per their higher ups, the network is not in need of additional SNF’s. We are utilizing some hospital documentation to see if we can get them to the table.

We did inquire with SummaCare about the northwest providers. They do have a network there as they still have a relationship with the Mercy’s. Awaiting a response regarding a contract.

AultCare

AultCare is interested in contracting with OASN. This is still in the discussion phase. We will provide details ASAP.

Aetna

As you all know, per our previous notification, Aetna will be opening its network to facilities, and will no longer have a delegated agreement with MNS. Aetna has requested detailed information from us for all OASN facilities interested in working with them. We have sent the spreadsheet to all facilities with directions on the columns that need to be completed. We need a quick turn around on this, and are asking for the information by Friday, May 26 th . We have to complete the spreadsheet and credentialing applications and Aetna will release the documents. We will review the language and rate and work with Aetna on both. We will keep everyone posted regarding the progress of this initiative.

We just met with Aetna last Thursday. They are still reviewing the network, and the applications received.

Meeting with Aetna two weeks ago. They would not confirm anything at this point, except that they are still evaluating.. Per information received today, they have opened the networks in Indiana and Illinois, and are still evaluating Ohio and Kentucky.

We have seen contracts for Indiana. The rates being offered are very similar to MNS rates, so they are too low. Aetna is willing to negotiate, however, so we will work on increasing the per diems, maximizing the levels and also pushing P4P.

Aetna is still reviewing all of the information received. We have received external information that it does look like Aetna will be opening the network, and this exercise will not simply fall by the wayside. Indiana is moving forward with direct contracting, and we will let everyone know as soon as we have a final decision from them regarding Ohio.

We have followed up with Aetna twice since the holidays. They are still reviewing, and did extend the period to submit to January 27th. We will follow up again next week regarding status. Also, we do know that Aetna is taking direction from

hospitals, so if you have a relationship/contract with respective hospitals in your region, have them contact Aetna, or better yet provide written support for your facility.

OASN did submit collaborative data to Aetna on December 15th. 79% of the OASN providers reporting have a 3 star rating or better. 39% are five star facilities, 27% are four star and 13% are three star. We also pointed out that, although we recognize the significance of the star rating, OASN has its own, internal quality program and we did provide collaborative information regarding the various measures including our low rehospitalization rate. Just because a provider experienced an incident that dropped their star rating does not mean they are not a quality provider. This is what our information stressed.

We will keep you posted as we receive feedback from Aetna.

Anthem

Anthem Government Relations requested additional information on the OASN providers which was provided. We will continue discussions with them regarding the current Medicare network and MLTSS.

The Anthem inservice for facilities that have signed on for the care management program to enhance the Level of Care approved and paid by Anthem will be held at Jennings Center on June 1st at 1:00 p.m. We are planning to have another in the western part of the state as soon as we get a location solidified. For any facilities in the west or northwest that voted for this program, you can attend the northeast meeting as well, if you prefer to meet next week. Just let Carolyn know.

We met with Anthem’s government relations on Wednesday (4/26). They are interested in OASN’s P4P, and discussed their interest because they are bidding on the MLTSS. They did share that partnering on this could also help shape the Medicare network as well. We are continuing discussions.

In addition, they shared that if a provider loses its status due to a low star rating, once the rating increases back to a 3 or above, the facilities can be reinstated. We do have some providers that were terminated due to their star rating. We did argue for the quality of the OASN providers based on our metrics. In addition, we have submitted additional information

as provided from facilities based on their star rating history. We are also arguing that all payors, not just Anthem look a facility’s history of quality, not just one rating. Pam Richmond gave me permission to send the attached summary they did on behalf of Otterbein Portage Valley. This is exactly the type of documentation we are looking for to use with all payors. Remember, MMO is also looking at star ratings as well as Aetna. So, if your facility has dropped below a 3, and you have a history of strong ratings as well as the plan of action, please provide it to us, so we can submit to the payors.

The appeal for the OASN members terminated from Anthem’s Medicare network was submitted last week. If any other providers have received term letters, please let us know immediately.

Additional changes were made to the HealthAgree documents. They are now in final format and were submitted to Jim Formal for signature. We received the signed document from Jim, and will now forward the individual documents to those that have expressed interest in participating.

We have received the final documents from HealthAgree. We will review and provide Jim Formal with the contract for signature. We will also provide the individual providers participating in this project with their documents as well. Dates for the educational seminars will be sent.

Anthem has begun narrowing their network. We have received notice from six OASN members being removed from the network. All have been low volume and low level admissions (2 or lower). We will be appealing as OASN for all providers that are being affected. We will be including information for all of OASN, and stress the need for them to look at the network as a whole, and to consider the quality component. We do have a meeting set with their government relations head on 4/26/17 to discuss a quality contract with them.

Steve was approached at the statehouse after presenting OASN to the legislature inclusive of the quality data and dashboards. Anthem’s government relations VP approached him, and wanted to schedule a time to talk about OASN, and what could possibly be done with Anthem. She was very impressed with what OASN has put into place. In speaking with Josh, he confirmed that government relations at Anthem is driving these discussion, because of their huge Medicare population. That meeting is currently being set.

I had asked for facilities interested in the HealthAgree care management program to increase Anthem reimbursement to let me know by 2/28 if you wish to participate.  We did receive some additional responses, but have not heard from

several providers. At this point, we are going to start with the list of providers currently interested. We will be scheduling meetings for those providers beginning in April. We are working on the overall OASN agreement with HealthAgree, and also the individual documents. We will get those out as soon as they are in final form.

We have discussed with Josh how to price this project for the providers that are signing on now versus those that may want to participate in the future. We are looking at a discount for providers that are signing up for this program now, and a higher rate for those that choose to participate later. We are negotiating with Josh currently, and will provide the final numbers.

In addition, we had received information that Anthem was considering additional facilities. As you will recall, Anthem had closed their network in the spring of 2016. We did send surveys for completion to the providers that did not contract with Anthem previously to see if we can get them added. We have submitted the completed surveys to Anthem, and are currently awaiting feedback.

Buckeye

We have a follow up meeting with Buckeye on May 31st, and will continue weekly meetings until a P4P deal is reached.

We met with the VP of Buckeye and Linda Julian to discuss the P4P contract. Per Eric, they are aggressively pushing forward to get a P4P contract in place ASAP. Below is a list of potential items that will be addressed in this agreement:

They are interested in OASN providers, and also adding additional facilities in specific regions. However, they want the simplest model, and would like OASN to be the facilitator of building upon what has been established. This would be done along with LeadingAge, and any LeadingAge facility that is not in OASN would need to contract with OASN to be part of the P4P contract with Buckeye.

They do want to look at re-admissions and a possible shared savings. We did go through the OASN proposal as well, and they were receptive our methodology as well (see attached).

They also want to look at falls which ties to readmissions and also the transition to home. They were receptive to a dedicated Buckeye representative for OASN They were receptive to eliminating the authorization requirement

Interested in a data exchange – we discussed Civic Health’s platform and the ability Buckeye could have to share information via the platform

F/U meeting being scheduled for next week The meeting with Buckeye to discuss P4P has been pushed to 5/2. This will be in person with their VP and Linda

Julian

Also, Buckeye is planning on rolling out Medicare Advantage in the nine counties surrounding Cleveland and Cincinnati..

We have a follow up meeting with the VP of Buckeye and Linda Julian to discuss implementing the P4P on April 4 th.

Also, one of the providers shared that there was a change in leave day reimbursement for duals patients.  We have not received any notification of any change such as this, and it would require notification as it would be a material change.  I have asked our contractor to clarify, and will let everyone know when we get a definitive answer.

CareSource

We met with CareSource again on 5/23/17. We discussed details of the potential P4P discussing the relinquishing of administrative burden, and a per diem rate with pharmacy and therapy carve outs. Dr. Lopez was very engaged; however, when we did bring up the ongoing issues we are experiencing with CareSource to Mark Grippi, he said we will need to talk with Steve Ringle as Mark will be leaving the company next week.

We are leery about any new deal with CareSource as so many issues have gone unresolved. We will see how Steve Ringle responds and if he will assign someone to us to finally get resolution on all issues. Anything short of this could be deal breaker for OASN based on the provider feedback.

We met with CareSource along with LeadingAge on 5/9/17. They are also pushing toward finalizing a P4P agreement. However, during this meeting, the contracting staff contradicted the network model and would not commit to a more exclusive arrangement. Subsequent conversations with Mark Grippi’s boss were more beneficial. He understands that there are still many operational issues that need to be resolved and is open to a more exclusive deal.

So, we are now working toward a 7/1 implementation date of a P4P arrangement as a preferred network. This could then lead to exclusivity. OASN would be open to possible additional facilities, if necessary that meet the published requirements. The rates will likely be in per diem methodology with enhanced payment for specific quality measures. Meetings are scheduled for 5/19 to further discuss the details.

We did meet with Antoinette Geyer and her team on the 21st. We did get contacts to address the incorrect address issue. All information has been submitted to these contacts. They are also going to review providers that we have identified as not showing up in their system under OASN, and the remaining providers after that to make sure everyone is loaded. They did try pushing back, and stating that this should be done through Mark Grippi’s team. They have things extremely segmented, so we have a meeting scheduled with Mark, his boss and the VP of contracting on 5/2. We also have a follow up with Antoinette, her team and Mark for 5/5.

The meeting on 5/2 was scheduled to discuss specifics for a new P4P proposal. We do plan to present all current issues to them at that time, and require resolution before entering into a new agreement.

We have the follow up meeting scheduled with their VP for April 21st. Also, we have attached additional information regarding authorization updates for the MyCare product.

We will have the following up to the operations meeting previously held with the New VP at CareSource pertaining to all of the issues they are addressing for us. We have received another check in our office, and sent it directly to their attention. We are pressing them for answers, but will have the call next week (per their request) to get status.

The Medicare contract has been fully executed. See link below:https://www.caresource.com/providers/ohio/medicare-advantage/

Welcome to CareSource Medicare AdvantageWe offer three Medicare Advantage Health Maintenance Organization (HMO) plans in 14 Ohio counties (Butler, Clermont, Cuyahoga, Delaware, Franklin, Geauga, Greene, Hamilton, Lorain, Lucas, Mahoning, Montgomery, Trumbull, and Warren):

CareSource Advantage Zero Premium™ (HMO) CareSource Advantage® (HMO) CareSource Advantage Plus™ (HMO)

Our Medicare Advantage plans (Part C) provide members with all the benefits of Part A and Part B, plus prescription drug coverage (Part D).

We had a great meeting with CareSource’s senior leadership team today consisting of the Vice President of Health Partner Life Cycle which includes credentialing and payment issues, the Director of Credentialing and the Director of Health Partner Resources. We explained to them all of the issues that we continue to experience with CareSource including providers that still are not showing as in network, incorrect payment rates, and now checks being sent to Strategic Health Care. The team was very informative and helpful. We are providing the complete list of all OASN providers and all service lines and they will go through the system to make sure everyone is loaded correctly. They will also make sure payments are corrected, if necessary.

We will be meeting with them again in three weeks to go over the progress that has been made in regard to these issues.

Molina

The providers voted to approve the P4P amendment. We received the LOA, and have provided Molina with a redline including recommendations. They are reviewing, and will follow up with their response.

We met with the president of Molina and her staff on Friday (5/5). They have their initial P4P ready to implement. They are taking a different approach and have targeted their long term patients. We have attached the specifics of the program. If your facility meets the requirements and measures, additional monies will be awarded. There is no downside risk to this program.

In addition, we discussed Molina issuing a preferred listing to the hospitals to help drive volume to our facilities. This will also be a tool the facilities can utilize for marketing purposes. Molina is only doing the P4P agreement with OASN and CPAN.

We are still working with them in regard to implementing P4P on more specific measures and for a larger population. We will continue these discussions as the original plan rolls out.

We are meeting again with Molina in two weeks to continue the work on the P4P.

We met with Molina on 3/13/17. They are moving forward with the P4P proposal. Based on their data, OASN still looks better quality-wise than other SNFs in their network. They did run more current data, and found the quality to be consistently higher. They are continuing to address the medical cost ratio. Their numbers are not adding up, so they are doing some additional analysis, and will provide information back to us once this is complete. They will have language ready for the amendment in a couple of weeks.

In regard to the assisted living proposal, they will also have this update to us in a couple of weeks.

We are meeting with Molina next week. Please note that we have received notice from a few providers that they were being told their contracts were ending at the end of the year. We have looked into the situations brought to us, and they were not correct. We did recredential providers in November, and Molina was not on the same page in regard to the information submitted. The contractor has insisted no providers were termed.

We received the amendment for the enhanced payment for bad debt to continue in 2017. It was signed by Jim Formal, and submitted for counter signature.

We received the fully executed Amendment for the Exchange Product. It was effective on July 21st. We sent the contract report and contract out to the providers yesterday. The AgeNet providers were not part of the Molina contract originally, so we submitted to have them added when the organizations decided to merge. We are checking status with Molina to see if the AgeNet providers have been added, so they can also begin taking the Exchange patients as they present to the facilities. The rate is 100% of Medicare.

Gateway Health

We met with Gateway again on May 17th. They want to engage in regard to contracting with OASN for the Medicare product and also for potential MLTSS and the reprocurement. They will be sending documents for us to review and will reconvene with us the second week of June.

We are also working with Gateway Health. They currently have a Medicare product in the state of Ohio. They are part of HighMark out of PA. They also plan to bid on the MLTSS. Our contact came from another plan, and has been supportive of Strategic Health Care clients. They are interested in doing a preliminary engagement with the network inclusive of all services and specifying P4P components. They are interested in going at risk at some point. We are to continue discussions with the future plan president and vice presidents on the 18th.

AultCare

There is interest from AultCare for help in regard to their post acute care network. There is a potential for P4P or even at risk deal with them.

MediGold

We finally received the final document last evening. We will review to make sure everything has been addressed. If so, it will be sent to Jim Formal for signature this week.

MediGold did follow up and requested an additional document be signed, so they can finalize the agreement. The document was completed and sent. They are to send the final contract documents.

Everything has been submitted for all providers wishing to participate. We are now awaiting the credentialing process, and final documents. They are continuing to move toward adding home care. We did provide some additional information to them on this, and have requested the rate information. They did state that outside of Franklin county should not be an issue, but they are trying to get Franklin county providers included as well.

We received documents from MediGold, and have begun the re-application process for those facilities wishing to move forward with MediGold. MediGold is sticking with their current fee schedule, but did agree to do a one year agreement, with the ability to open for renegotiation. In addition, we have asked to add home care and hospice. They are still reviewing this request, and will let me know ASAP.

Facilities that have agreed to contract with MediGold are as follows:

Grace Brethren, Otterbein, Brethren Care, Bayley, Friends, Ohio Masonic – Springfield, Bethany (tentative)

UHC/Optum

We have been notified from some OASN members that are not contracted with UHC that they have sent Medicaid documents to these facilities to help build their network for MLTSS. We are advising any facility that receives this document to forward to our attention right away. UHC has not been willing to add certain providers for their other products, because their network is closed. We want to make sure that if our facilities are willing to sign for Medicaid, UHC is willing to work with these facilities on the other products as well. Again, please forward any UHC Medicaid documents to our attention.

We followed up with Optum to let them know that Maple Knoll was open to having their rounding program piloted in northeast Ohio. We also had a couple of facilities ask to participate, and UHC was identifying others. UHC is now working on the details of what the proposal for this will look like.

In addition, we are continuing discussions with Jeff Corzine regarding the potential exclusive arrangement for P4P and their proposed measures are listed below.

Met with Optum on 4/20/17. This discussion was much better than those in the past. We again reiterated our desire to finalize P4P. They have identified metrics that they wish to include, and many of those are ones OASN is tracking:

Care for older adults – med review, 66 and olderCare for older adults – status assessment, 66 and olderCare for older adults – pain assessment, 66 and olderControlling high blood pressure

F/U after hospitalization for mental illness – 30 dayAntidepressant Medication Management - acuteAntidepressant Medication Management – continuationPlan all cause readmissionsUtilization – Admission/1000Comp. Diabetes CareFlu vaccines for adults 65 and olderFalls risk managementPart D med adherence for Diabetes% of residents who were physically restrained – opt in% of residents who were physically restrained – opt out% of residents one more or more falls – opt in% of residents one or more falls – opt out% of residents with urinary tract infection – opt in% of residents with urinary tract infection – opt out% of high risk residents with pressure ulcers – opt in% of high risk residents with pressure ulcers – opt out% of residents who have/had catheter & left in bladder – opt in% of residents who have/had catheter & left in bladder –opt out

They also reported that they have seen improvement with OASN facilities in regard to the bypass rate. I have attached the most current data.

In addition, they would like to pilot the rounding program implemented at Maple Knoll with four or five targeted facilities in northeast Ohio. We are discussing this with Maple Knoll, and will be contacting the targeted facilities regarding participation, so we can draft the proposal.

In regard to P4P overall, we are continuing to move forward.

Optum finally responded. They have reviewed the P4P, and have additional feedback coming to us. In addition, we will be meeting with them again later this month to review the quality progress and P4P. Meeting to be held on 4/20/17.

Optum is not responding. They had asked for monthly JOC’s, and are not keeping the schedule with these. The ISNP amendment they sent still needs to be addressed, and they have acknowledged this, but are not responding on this either. We are looking for Jeff Corzine to help with UHC, but we have shifted our focus to the payors that have engaged and are moving forward.

Optum finally followed up last week, and asked if we would be willing to meet still this month. We responded with our willingness to meet with them again this week, but have not heard back from them. They have our proposal, and this will be discussed during the next call. In addition, we will provide current UHC reports, when they are received.

We did forward to UHC/Optum follow up with a list of items they were to address. We did receive a response with answers to specific questions (attached), and also with an outline of what OASN members need to do for additional/enhanced payment:

The OASN group is looking to secure a clear outline of tasks to achieve their next financial increase.o The group discussed the ways to achieve financial increases for the OASN facilities was to:

Maintain a Utilization score of 290 or lower (with a stretch goal of 250). Maintain an Untimely Notification score of 20% or lower. Create a collaborative environment that encourages constant communication between Optum and Facility staff.

We are trying to confirm if Optum will alter their methodology for calculating the hospitalization rates, and make it more conducive to nursing facilities. I am waiting to hear back. In addition, I have been asking for feedback from the facilities in regard to the correctness or incorrectness of the reshospitalization and bypass data Optum has shared. I have only received a few responses, and providers are sharing that they don’t necessarily have this data, and in some cases, they have shared that a process has been worked out with Optum care managers on how to report hospitalizations, but Optum doesn’t seem to be capturing the data. So, I have asked Optum to look into this for us, but have not received any feedback as of yet.

We have also requested that UHC include the Medicare and commercial products in their P4P.

Lastly, we have received the new P4P documents. We did receive clarification on the changes. They have reduced the number of measures, but did increase the reimbursement on some. We have not yet sent these documents on to the

providers as we know UHC wants these, because their ISNP business is their focus. Since we are still trying to get them to do the P4P contract for the other business, this will give us a little leverage with them.

Paramount

We have a call today to discuss the OASN network again with Paramount. They, too are being pushed by MLTSS, and we are talking with them because of the carve out in the northwest. The goal is to get all providers interested in contracting with Paramount under OASN to be able to be part of the contract for all products.

P4P ProposalsProposals have been presented to Molina (they are very receptive, and have provided language of their own, inclusive of an enhanced assisted living rate. They are reviewing both proposals, and will be re-grouping with us in March.

Proposals have also been submitted to CareSource, Aetna Better Health, and UHC. In addition, we did provide preliminary information to Aetna commercial/Medicare as well.

Unplanned hospital admissions All cause ER visits – short term All cause ER visits – long term Short term 30 day return to community

Aetna Better Health

Please see attached for additional information regarding changes for specific codes that will require records be submitted with the claim for services.

We also received information during the contracting call that one of the facilities had been told by ABH that they could not figure out the PL issue in regard to recouping overpayments, so just consider the money a free loan for now.  I did confirm with our contractor that they have indeed said this.  Please see below:

Hello Carolyn,

I appreciate you sharing the information below and wanted to connect you with Melissa Shriver who is a provider relations liaison in our central region.  She’ll be able to work with the providers on the claim issues.  Yes I guess you could consider it free for now but we will look to remedy the overpayment and recoup the funds.  Per the contract the facilities should actually send the money back to Aetna once they identify an overpayment section 4.1.2 second paragraph. 

Melissa will need to understand the facilities and claims impacted.  She will also provide direction to next steps. 

Thanks,

Matt Koblens

Ohio Senior Network Manager

Aetna Better Health of Ohio

The one thing Matt mentions in the contract language stating overpayments should be returned.  We know that several of you have tried this, and it is not working either.  I did remind Matt that this particular issue was separated out and worked at the collaborative meetings with the state and the payors.  They came up with the process, but all payors seem to be having issues with this still.  So, for those of you who have money on your books that needs to go back to Aetna Better Health, please go ahead and provide the PL spreadsheets to me, and we will coordinate with Melissa.

MMO

We met with Don Pirc and Teresa Vick on 4/11. They shared their strategy of narrowing their network and that they are looking at the star rating as part of this. We did encourage them to review the OASN quality data, and also a history of star ratings versus just the current as one incident could drastically change the rating. They agreed with this approach as well.

They did ask for follow up information. We provided all of the documentation requested. We also proposed a meeting between their medical directors and our quality staff to discuss what we are tracking and the outcomes associated. They agreed this was a good approach. I did receive confirmation from Don that they were reviewing all information, and would get back to me with potential times for the meeting.

Meeting with Don Pirc on 4/11/17.

We are meeting with Don in Columbus next week to go through their work plan for restructuring their network.

Don Pirc followed up on 2/2/17 requesting additional information regarding the OASN providers. He stated that they were ready to begin contracting. I forwarded him all of the requested information including the dashboards, and P4P initiative. I am awaiting a response from him regarding our next steps. We have followed up twice in regard to the status of this agreement, but have not heard back since February. We will go back to the VP of sales again, if necessary.

Don Pirc did follow up last week with a message that he had hoped to have something to me by the end of last week. That didn’t happen. In the meantime, I received a message from MMO’s sales department wanting access to our providers to market their Medicare product. We were able to get many of the OASN members contracted prior to the closing of MMO’s Medicare network, but there are others that still have not been added. This actually gives us some leverage to work on a unique P4P with our OASN members. We have sent this information to Don, and also responded to the MMO sales force.

We did follow up with the head of Medicare Sales for MMO again as well as the VP of contracting. Don Pirc did respond as follows:

From: Pirc, DonSent: Tuesday, January 10, 2017 8:33 PMTo: Carolyn Roten; Larkins, SteffanySubject: RE: Follow up from call on 8/11

Hi Carolyn:We actually met with the consultant we hired to review where we are going in this space last week to gain further insight into what the network should look like. So we are close.

I'll reach out to some internal people to either get a hard date when we will be ready or to see if we'd be willing to review your facilities sooner since we know you've been waiting for an answer for a while. I'll be in touch soon.

Cigna

Cigna has not responded to the counter on the hospice and therapy rates. I have pushed back to renegotiate the SNF rates, since this negotiation has taken so long. We are still pushing the P4P as an alternative.

We are now moving with Cigna again. We did receive therapy and hospice rates that Cigna is willing to negotiate. We collected feedback from the providers regarding the proposed rates, and did provide a counter proposal to Cigna. We are now awaiting their response.

Humana

We have received applications for one facility, and per Humana, they are researching to find out which additional facilities will be extended an agreement. We are still pushing for all providers interested at this point, and will leverage the out of network Medicare products as we work through this. We did discuss going out of network in regard to Humana referrals to help leverage overall contracting.

Industry UpdatesThe mergers between Aetna/Humana and Anthem/Cigna will not be finalized. Updates were released last week on both. We will continue to work on separate agreements.

Premiere

They have sent an amendment to add the contracted facilities to the ACO product. We have the documents, but the main language references the CMS agreement, which Premiere states will be provided to the facility once the

amendment is signed. We need to have that document prior to signing, so you know what you are signing up for. They are pulling this document for us to review. In addition, the rates will be the same, and there is a P4P provision, but it will be added at a later date.

Midwest Health Collaborative – we are re-engaging now that they have an ED. We have reached out, and awaiting a time for a meeting.