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Managed%20Care%20Supplemental%20Payment%20Program%20

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Title: Managed%20Care%20Supplemental%20Payment%20Program%20


1
Managed Care Supplemental Payment Program 2008
Update
May 28, 2008
Moderator Kate Breslin, CHCANYS Presenters
Peter R. Epp, RSM McGladrey Helen Pfister,
Manatt Phelps Phillips, LLP Scott Morgan,
RSM McGladrey Lynn Sherman, Charles B. Wang CHC
2
Technical Tips to this Webinars Technology
  • Polling questions We will be asking several
    questions during the course of todays webinar.
    Your responses are confidential and will help us
    to identify key issues. Please respond!
  • If you would like to post a question to
    presenters Use the button in the top, left side
    of your screen that says QA. Click on it,
    type in your question, then click on Ask.
    Well take a couple of breaks during the webinar
    to go over questions asked by participants.
  • We encourage all participants to register, even
    if it is after the event. We will use the
    registration list for future email correspondence
    about this and related issues.

3
Poll Questions 1-A and 1-B
  • How many MCOs does your center have
    Medicaid/Family Health Plus contracts with?
  • None One Two to three Four or more Dont
    know
  • How many Independent Practice Associations (IPAs)
    does your center contract with for Medicaid/FHP?
  • None One Two to three Four or more Dont
    know

4
Agenda
  • Overview of the Managed Care Shortfall Payment
    program
  • Managed Care Contracting
  • Shortfall Payment Rate Calculation
  • Billing Requirements
  • MCVR Reporting

5
Overview of the Program
  • Federal law requires states to make supplemental
    payments to an FQHC for services furnished
    pursuant to a contract between the FQHC and a
    Managed Care Organization (MCO) for the amount,
    if any, that the FQHCs PPS rate exceeds the
    amount of payments provided under the managed
    care contract for the services rendered by the
    FQHC.
  • On February 25, 2008, the New York State
    Department of Health (DOH) distributed to all
    FQHCs the NYS Managed Care Supplemental Payment
    Program Policy Documents which consolidate
    policies related to this program, previously
    conveyed via letters, into a single source.

6
Overview of the Program (contd)
  • All FQHCs participating in the Program are
    required to submit electronic copies of their
    duly executed managed care contracts between the
    FQHC and the MCOs/IPAs on CD to DOH by June 1,
    2008 (per Section III.B. of the Policy Document)
    to remain in the program.
  • The 2007 Managed Care Visit and Revenue (MCVR)
    report and corresponding Certification Form must
    be submitted to DOH by July 1, 2008, to apply for
    participation in the Program for October 2008
    September 2009.
  • Instructions are included in Attachment A of the
    Policy Document.

7
Overview of the Program (contd)
  • In order to qualify to receive supplemental
    payments, each FQHC must
  • Have a PPS rate in effect for the time period and
    site where services were provided to an MCO
    enrollee
  • Have an executed contract for Medicaid and/or
    Family Health Plus (FHP) with the MCO or an
    Independent Practice Association (IPA) that
    contracts with an MCO, for the time period and
  • Must have received an MCO payment for services
    rendered that is less than the FQHC would have
    received for those same services under the PPS
    rate.

8
Submission of Qualifying MCO/FQHC Contracts
  • Contracts must be between the FQHC and the MCO.
    Contracts between the MCO and individual
    physicians, even if employed by or working at
    FQHC sites, do not qualify for FQHC supplemental
    payments.
  • Contracts between the FQHC and an Independent
    Practice Association (IPA) are acceptable if the
    IPA has a corresponding contract with an MCO, the
    contract explicitly covers Medicaid and/or Family
    Health Plus, and the FQHC can separately identify
    visits associated with each MCO that contracts
    with the IPA. The IPA and its associated MCO must
    be reported on the MCVR report. Contracts between
    the IPA and individual physicians do not qualify
    the FQHC to receive supplemental payments.
  • All contracts must clearly indicate which
    specific primary and specialty care services are
    covered.

9
Submission of Qualifying MCO/FQHC Contracts
(contd)
  • The contract period must be in effect during the
    supplemental payment period.
  • Contracts with effective dates prior to the
    supplemental period are acceptable if they
    contain renewal language or signed dated
    amendments that clearly indicate the contract is
    in effect during the supplemental payment period.
  • Contracts with automatic renewal clauses with
    effective dates prior to the supplemental rate
    period in question that do not specifically
    indicate they are effective during the
    supplemental period must include a signed
    attestation from the FQHC and the MCO that the
    contract is in effect during the supplemental
    period, if the effective date of the contract is
    more than two years old.
  • For example, contracts for the October 1, 2008
    through September 30, 2009 supplemental payment
    period must be effective no earlier than October
    1, 2006, or they must be accompanied by the
    attestation. The attestation must be a letter
    signed by the Chief Executive Officer of both the
    MCO/IPA and the FQHC attesting that the contract
    and payment terms were in effect during the
    supplemental payment period.

10
Submission of Qualifying MCO/FQHC Contracts
(contd)
  • The specific payment terms of the contract must
    be submitted with the contract for the applicable
    period, including all relevant payment schedules.
  • All complete contracts must be dated and duly
    executed.
  • An electronic copy of each completed contract for
    each MCO and/or IPA listed on the MCVR report
    must be submitted to DOH, in a standard
    searchable PDF format on a closed session CD-R
    (not CD-RW), with copy/read permissions. The CDs
    must be clearly labeled identifying the FQHC and
    the contracts included.

11
Submission of Qualifying MCO/FQHC Contracts
(contd)
  • Additional submission guidance for 2008 was sent
    by DOH on April 30, 2008.
  • A Managed Care Contract Attestation form must be
    included as part of the June 1, 2008 contract
    submission.
  • If more than fourteen (14) contracts are
    submitted, multiple forms must be used.
  • A completed copy of the Attestation form must be
    electronically included as an Excel document on
    the CD along with a signed hard copy.
  • The contracts included on the CD must correspond
    with the contracts listed on the Attestation form.

12
Submission of Qualifying MCO/FQHC Contracts
(contd)
  • Real Life Applications
  • How do you negotiate with MCOs to revise the
    contracts to be in the name of the FQHC facility
    and not the individual physician?
  • What is searchable PDF format on a closed
    session CD-R (not CD-RW), with copy/read
    permissions and how do you copy contracts onto
    the CD?

13
Poll Question 2
  • How many of your Medicaid managed care contracts
    are with individual providers and NOT in the name
    of the Center?


Zero (All are in the name of the Center) One Two Three or More Not Sure
14
Calculation of Shortfall Payment Rate
  • Each qualifying FQHC's "supplemental payment" is
    the average difference between what that FQHC is
    paid by contracted MCOs and its specific PPS rate
    for each year. FQHCs bill eMedNY directly for the
    supplemental payment, for services provided to
    contracted MCO enrollees that would otherwise
    qualify under Medicaid fee-for-service rules for
    payment at the FQHC's PPS rate.
  • In 2007, DOH revised the rate-setting methodology
    retroactive to October 1, 2005
  • Converted to a prospective payment system
  • Changed the rate calculation from using a
    weighted-average Medicaid fee-for-service rate
    base to the PPS rate

15
Calculation of the Shortfall Payment Rate (contd)
  • The 2007 MCVR will be used to determine the
    average managed care revenue per visit in the
    Shortfall payment rate calculation for the period
    10/1/08 9/30/09.
  • The following table illustrates the change in the
    Shortfall payment rate calculation.

Historical Calculation New Calculation
Clinic rate (PPS) 147.88 147.88
PCAP 175.00
HIV enhanced rates 150.00
Total Fee-for-service 151.30 147.88
Medicaid managed care 90.00 90.00
Shortfall payment rate 61.30 57.88
16
Calculation of the Shortfall Payment Rate (contd)
  • The supplemental payment amount will vary by FQHC
    depending on its Medicaid PPS rate and its
    contract terms with MCOs. The FQHC specific
    average managed care payment per visit will be
    determined based on data provided on the MCVR
    Report. FQHCs must list
  • Each contracted MCO (whether contracted directly
    or indirectly through an IPA contracted with an
    MCO),
  • The number of threshold visits each MCO/IPA paid
    the FQHC, and
  • The average MCO/IPA payment per threshold visit.
  • The CEO/CFO must sign an attestation to the
    accuracy of the submitted report.

17
Calculation of the Shortfall Payment Rate (contd)
  • While the MCVR report is submitted on a calendar
    year basis, the supplemental payment rates are
    effective for the same time period as the PPS
    rate, which is October through September.
  • Once determined, average managed care payment
    rates for each year will not be further adjusted.
  • If the FQHC's Medicaid PPS rate changes, the FQHC
    should notify DOH and the supplemental payment
    rate will be updated based upon the revised PPS
    rate for that period.

18
Criteria for Submitting Supplemental Payment
Claims
  • FQHCs may submit supplemental claims to eMedNY
    for Medicaid and/or Family Health Plus enrollee
    visits (Child Health Plus visits are not
    eligible) provided per a contract with an MCO,
    for services that would otherwise qualify under
    Medicaid Fee-for-service (FFS) for payment at the
    FQHC's Prospective Payment System (PPS) rate
    code.
  • The FQHC must either contract directly with the
    MCO or indirectly through an IPA that contracts
    with an MCO.

19
Criteria for Submitting Supplemental Payment
Claims (contd)
  • Managed care supplemental claims may be submitted
    by the FQHC only if the following criteria are
    met
  • The FQHC must have an FQHC PPS Medicaid rate in
    effect for the date of service and site of
    service.
  • The FQHC must be contracted with the enrollee's
    MCO either directly or through an IPA that
    contracts with the MCO for the service provided.
  • Only one supplemental claim can be submitted for
    an enrollee for a given day. One supplemental
    claim is allowed per threshold visit.
  • The FQHC must have evidence of a paid claim from
    the MCO or IPA, if the contract is on a
    fee-for-service basis. Supplemental claims cannot
    be billed for visits for which the MCO denies
    payment.
  • Under Medicaid FFS, the visit would have been
    billed under the PPS rate. For example, group
    counseling and offsite visits are not eligible
    for supplemental payments, as they are not paid
    at the PPS rate.

20
Criteria for Submitting Supplemental Payment
Claims (contd)
  • Only visits for mainstream Medicaid and Family
    Health Plus are eligible for supplemental
    payments. For example, Medicare/Medicaid
    Advantage and Child Health Plus enrollee visits
    are not eligible for supplemental payments.
  • The Policy Document indicates that
    Medicare/Medicaid Advantage enrollee visits are
    not eligible for supplemental payments. CHCANYS
    is actively engaged in reversing this decision as
    it is inconsistent with the FQHC PPS
    requirements.
  • Visits NOT eligible for supplemental payment
    include the following
  • Visits for which there is no managed care
    contract between the FQHC and the MCO.
  • Visits for contracts between MCOs and individual
    provider.
  • Visits that under Medicaid PPS rules would not be
    eligible to be billed at the FQHC PPS rate code,
    i.e. a Medicaid enrollee receives treatment
    during a threshold FQHC visit, which cannot be
    completed due to administrative or scheduling
    problems (e.g., follow-up laboratory testing or
    radiology procedures).

21
Polling Question Number 3
  • How many of your MCOs send you remittance advices
    for visits covered under capitation arrangements?


All None Some Not Sure Not Applicable (No Capitation Arrangements)
22
Poll Question 4
  • How many of your MCOs submit electronic
    remittance advices for payments made?


All None Some Not Sure Not Applicable (No Capitation Arrangements)
23
Poll Question 5
  • For visits covered under capitation arrangements,
    as indicated on the remittance advices, do you
    post the MCOs approval in your Practice
    Management System?


Yes No Not Sure Not Applicable (No Capitation Arrangements)
24
Poll Question 6
  • Is your Practice Management System able to
    generate a report of PAID visits by MCO and
    government program?


Yes No Not Sure
25
MCVR Form and Instructions
  • The Managed Care Visit and Revenue Report must be
    completed by each FQHC in order to receive
    Supplemental Payments under this program.
  • The report identifies each MCO that the FQHC
    directly contract with, as well as any indirect
    contracts through an IPA, along with the number
    of visits and amount of MCO payments, for
    Medicaid and Family Health Plus (FHP) enrollees.
  • Specific instructions for completion of the
    report are included as Attachment A to the Policy
    Document, along with the report format
    (Attachment B) and the Certification Form
    (Attachment C).

26
MCVR Form and Instructions (contd)
MCVR Reporting Form
Medicaid Medicaid Medicaid Medicaid Medicaid
MCO Name IPA Name Number of Visits Paid By MCO/IPA MCO/IPA Payments to FQHC Withhold Adjustment (if any) Adjusted MCO/IPA Payments to FQHC Average Rate per Visit
A B C D B C E D/A



Total
Note Columns A through E are replicated for FHP
as columns F through J.
27
MCVR Form and Instructions (contd)
  • MCO Name
  • Enter the MCO name with which your FQHC has a
    direct managed care contract. MCOs include
    Prepaid Health Service Providers (PHSPs), Health
    Maintenance Organizations (HMOs). Do not report
    any contractual arrangements other than those
    with an. MCO or with and IPA that contracts with
    an MCO.
  • IPA Name
  • If the information being reported is through a
    contract directly with an MCO, leave this field
    blank.
  • If the information being reported is through an
    IPA contracted with the MCO, enter the IPA's
    name. Continue to report the visits and revenue
    associated with payments from the IPA for
    enrollees in the MCO reported under MCO Name.
  • Note, visits and revenues through an IPA must be
    reported by the MCO. If an IPA contracts with
    multiple MCOs, the visits and revenues associated
    with each MCO must be reported separately.

28
MCVR Form and Instructions (contd)
  • FQHC Visits Paid by MCO/IPA
  • Enter the total number of visits paid by the
    MCO/IPA to the FQHC (Column A for Medicaid and
    Column F for FHP). In order the count as a visit
    for purposes of determining your managed care
    supplemental payment rate, the FQHC must have
    received payment from the MCO/IPA for that visit
    and included such amounts in Column B for
    Medicaid and Column G for FHP.
  • Only visits that would have been paid at the
    Prospective Payment System (PPS) rate code under
    Medicaid fee-for-service should be reported.
  • If the MCO pays the FQHC for more than one visit
    per day, report all MCO payments for that day,
    but only one (threshold) visit.
  • Group counseling and off site visits should not
    be reported.

29
MCVR Form and Instructions (contd)
  • MCO/IPA Payments to FQHC
  • Enter the dollar amount of payment received by
    your FQHC from' the MCO/IPA for the report
    calendar year (January - December) in Column B
    for Medicaid and Column G for FHP. This must
    include any capitation payments, as well as
    fee-for-service payments received by the FQHC
    from the MCO/IPA.
  • Financial incentive payments received by the FQHC
    from the contracting MCO/IPAs are not included in
    the calculation of managed care supplemental
    payments under the Balanced Budget Act (BBA).
    Therefore, do not include any bonus payments made
    to the FQHC in Column B for Medicaid or Column G
    for FHP. (A Bonus is a financial incentive
    payment above and beyond the amount otherwise due
    to a provider under the terms of the contract and
    made to the provider according to terms and
    conditions spelled out in the contract.)
  • If the FQHC receives a global payment that
    includes services other than those that would
    have been billed at the FQHC PPS rate, (such as a
    global fee for prenatal/delivery/postpartum) only
    report the portion of MCO reimbursement related
    to the FQHC PPS rate.

30
MCVR Form and Instructions (contd)
  • Withhold Adjustment (if applicable)
  • Enter any amount of withhold from the FQHC
    payments by the MCO/IPA, not reported in Column C
    for Medicaid and Column H for FHP. (A Withhold
    is a portion of a baseline payment that would
    otherwise be due to a provider but is withheld
    under the payment terms of a contract, which is
    partially or totally returned to the provider
    under agreed-to terms and conditions.)

31
MCVR Form and Instructions (contd)
MCVR Reporting Form
Medicaid FHP Combined
MCO Name IPA Name Average Rate per Visit Average Rate per Visit Average Rate per Visit
E J K



Total
Note Column K represents the average of both
Medicaid and FHP managed care revenue per visit
and is utilized in the Shortfall payment rate
calculation.
32
MCVR Form and Instructions (contd)
MCVR Reporting Form Calculation of Managed Care
Shortfall Payment Rate -
FQHC PPS Rate less Recruitment and Retention Enter most current PPS rate
- Total Average Rate Per Visit Automatically calculated from Column K, Line 26
Calculated Supplemental Rate Supplemental rate is subject to verification and approval of information submitted
33
MCVR Form and Instructions (contd)
  • Real Life Applications -
  • How do you access paid visits from the Practice
    Management System?
  • How do you compile paid visits and payments
  • By MCO?
  • By MCO and Government Program (e.g. Medicaid and
    FHP)?
  • By IPS and MCO and Government Program?

34
Poll Question 7
  • How many of the rosters you receive from your
    MCOs segregate members by Medicaid, FHP and CHP?


All None Some Not Sure Not Applicable (No Capitation Arrangements)
35
Poll Question 8
  • Do you update your Practice Management System on
    a monthly basis for active members by MCO and
    government program as indicated on the rosters?


Yes No Not Sure Not Applicable (No Capitation Arrangements)
36
Polling Question Number 9
  • Do remittance advices from IPAs (e.g. Doral
    Dental, Block Vision) indicate for each member
    the underlying MCO with whom the IPA has a
    subcontract?


Yes No Not Sure Not Applicable (No Capitation Arrangements)
37
Determining the MCVR Data Validation
  • The information on submitted MCVR reports may be
    validated by the DOH
  • Medicaid paid supplemental claims billed by FQHCs
    for the period, MCO encounter data showing paid
    FQHC visits, MCO Medicaid Managed Care Operating
    Reports (MMCORs) which list contracted FQHCs and
    paid visits, or any other data sources available
    to DOH. For example, an FQHC's reported average
    managed care rate on the MCVR report may be
    verified using the actual proportion of visits
    paid by each MCO for the prior period, based on
    the FQHC's billed supplemental payments for that
    period.
  • DOH may choose to accept the MCVR report and
    contract documentation as submitted, based on the
    attestation of data accuracy signed by the FQHC's
    CEO. The MCVR report is subject to future audit
    by the Office of the Medicaid Inspector General
    (OMIG).
  • If, however, the information on MCVR reports or
    contracts is so inadequate that a shortfall rate
    can not be established the FQHC may be deemed
    ineligible for the time period in question.

38
Summary and Best Practices
  • Design systems NOW to capture all of the
    information required for reporting on the MCVR.
  • Establish procedures for recognizing paid
    visits in the Practice Management System.
  • Only bill the Shortfall Payment rate for paid
    claims.
  • Work with MCOs to provide the data necessary to
    properly complete the MCVR.
  • Regular review your Managed Care contracts and
    Shortfall Payment rate billing for compliance as
    part of your corporate compliance activities.
  • Monitor/Project increases and decreases in
    managed care revenue per visit, and its
    implications on patient revenue, both currently
    and in to the future.
  • Be prepared when the OMIG comes a knockin!

39
Questions
40
Contact Information
  • Kate Breslin, CHCANYS Director of Policy
  • KBreslin_at_CHCANYS.org
  • Peter R. Epp, CPA, RSM McGladrey Managing
    Director
  • Peter.Epp_at_rsmi.com
  • Helen Pfister, Esq., Manatt Phelps Phillips,
    LLP Partner
  • HPfister_at_Manatt.com
  • Scott Morgan RSM McGladrey Director
  • Scott.Morgan_at_rsmi.com
  • Lynn Sherman, Charles B. Wang CHC CFO
  • LSherman_at_CBWCHC.org
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