New program helps counties contain inmate medical costs

Costs associated with inmate medical care can be extremely burdensome and a significant drain on county budgets, and many inmate medical expenses are paid without the benefit of discounted or negotiated network rates.

To help alleviate this financial strain, the NCACC has partnered with Gilsbar, Inc. and the Willis Group to create an Inmate Medical Cost Containment Program. This program, which began July 1, will reduce annual expenditures for in-patient care and provide counties and sheriff's departments the same type of claims management and discounts that are available to many private employers and organizations.

For counties that choose to enroll, Gilsbar, Inc. will administer a claims payment system that provides the following services:

• a secure web tool for enrolling and activating inmates into the claims system when a "life event" is triggered;
• a single "Payer ID" card under which provider services will be billed and routed to Gilsbar for processing;
• tracking, verifying and archiving of each life event claim once the inmate is entered into the system by the Sheriff's Department;
• access to national networks of healthcare providers and pre-negotiated contract rates for the medical services billed to the Payer ID card; and
• review of bills for accuracy, medical necessity and fraud detection.

Gilsbar will translate bills into claims and pay providers according to the network contracted rate on a weekly basis, or provide notice to the county on the amount to pay the provider. To ensure that accurate payments are being made by the counties to providers, Gilsbar will process electronic claims through the Automatic Claims Processing System (ACPS).

The processing system provides more than 300 edits, all of which can be controlled at a specific county level. Claims that successfully pass all of these edits are paid without any intervention. Claims that do not pass all of the edits are submitted for a higher level of scrutiny by a claims analyst and may be recommended for denial, pended for further negotiation, or suspended.

Gilsbar will also provide enrolled counties a utilization management program that helps improve health outcomes through personalized care and monitoring. Effective monitoring of utilization can also reduce counties' inmate healthcare costs by lowering readmission rates.

The program operates on a true, flat dollar "pay as you go" model. Counties will pay a flat fee for each claim, but are not required to use the system even if they sign up for the service. This enables counties to base their utilization of the service on the severity – and likely expenses – of each claim. For smaller incidents that will not require extensive treatment, counties will have the option to decide if it is more cost-effective to simply pay the costs instead of filing a claim.

Participation in this program will have no impact on budgets until claims are incurred. There is no fee to participate.

For more information, contact NCACC General Counsel Sharon Scudder at sharon.scudder@ncacc.org or (919) 719-1155.