Medicare
Advantage Implications for RHCs TOP |
Slide 1: Medicare
Advantage Implications for RHCs
RHC Technical Assistance Conference
Call
February 1, 2006
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Medicare
Advantage Implications for RHCs TOP |
Slide 2: Ron L. Nelson, PA
Health Services Associates, Inc.
2 East Main Street
Fremont, MI 49412
Phone: 231-924-0244
Fax: 231-924-4882
Email: nelson@hsagroup.net
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Medicare
Advantage Implications for RHCs TOP |
Slide 3: History
MMA - Medicare Modernization Act (2003)
Created Medicare Advantage
How is it different from Medicare Part D?
How is it different from Medicare Part C?
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Medicare
Advantage Implications for RHCs TOP |
Slide 4: Medicare Advantage
Provides
for two types of plans
- PFFS - Private Fee for Service
- Regional/PPO Plans
- Must provide service to the entire region as defined
by CMS
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Medicare
Advantage Implications for RHCs TOP |
Slide 5: Map of Region
Image:
Map of the United States with Medicare Advantage Regions
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Medicare
Advantage Implications for RHCs TOP |
Slide 6: Regional PPOs
- Require service to the entire region
- Relaxed network standards
- FQHC wrap around
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Medicare
Advantage Implications for RHCs TOP |
Slide 7: Regional PPOs
- Requires contract
- Negotiation of rates
- No requirement to pay RHC rate
- May pay RHC rate, if negotiated
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Medicare
Advantage Implications for RHCs TOP |
Slide 8: PFFS Plans
- No contract required/may sign contract
- "Deemed" status providers - If you accept beneficiary
card and provide treatment you are considered a participating
provider
- Beneficiaries may change plans monthly
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Medicare
Advantage Implications for RHCs TOP |
Slide 9: RHCs
Traditional Medicare
- Must be paid rate as determined by cost report
- Traditional RHC services billed to intermediary - paid
based upon AIIR
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Medicare
Advantage Implications for RHCs TOP |
Slide 10: RHCs
Paid
full cost for vaccines included in costs
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Medicare
Advantage Implications for RHCs TOP |
Slide 11: RHCs
- Bad Debt may be claimed if reasonable
effort made to collect (120 days)
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Medicare
Advantage Implications for RHCs TOP |
Slide 12: RHCs
Independent/
Provider-based (more than 50 Beds)
- Rate – all inclusive interim rate determined
by projected or actual cost report paid subject to caps
where appropriate.
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Medicare
Advantage Implications for RHCs TOP |
Slide 13: RHCs
Provider-based Less than 50 Beds
- Entitled to full cost per visit with
no limit
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Medicare
Advantage Implications for RHCs TOP |
Slide 14: Medicare Advantage
- Managed Care for Medicare beneficiaries
- Forms:
- Private Fee for Service (PFFS)
- Regional Network or PPO-plan (RPPO)
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Medicare
Advantage Implications for RHCs TOP |
Slide 15: Medicare Advantage
- Private Fee for Service (PFFS)
- Requires plans to pay rate to RHCs to equal cost based
reimbursement
- No contracts
- Patient driven - marketing to patients
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Medicare
Advantage Implications for RHCs TOP |
Slide 16: Medicare Advantage (FFS)
- May include Medicare Part A & B and Co-insurance portion
- May also include Medicare D or Pharmacy benefit
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Medicare
Advantage Implications for RHCs TOP |
Slide 17: Medicare Advantage (FFS)
- RHCs – CMS not requiring cost settlement
at this time.
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Medicare
Advantage Implications for RHCs TOP |
Slide 18: Medicare Advantage
Regional Network Plans (RPPO)
- Negotiate rates with RHCs
- Must cost settle (provider-based less than 50 beds)
- No requirement for full rate payment (Independent, Provider-based
greater than 50 beds)
- Must sign contract
- Wrap around not required for RHCs
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Medicare
Advantage Implications for RHCs TOP |
Slide 19: Negotiation
- Some issues in managed care may be negotiable
- Develop a rationale for desired contract changes
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Medicare
Advantage Implications for RHCs TOP |
Slide 20: Negotiation
- Will you sign a contract with the managed care organization?
- Does the plan limit the types of medical services that
you can provide?
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Medicare
Advantage Implications for RHCs TOP |
Slide 21: Marketing
- How many lives does the plan insure?
- Who are the major employer groups?
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Medicare
Advantage Implications for RHCs TOP |
Slide 22: Financial condition of the plan
- Who owns the plan?
- What is the history of the plan's payments to providers?
- What is the experience of other providers?
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Medicare
Advantage Implications for RHCs TOP |
Slide 23: Practice management
- What laboratories participate in this plan?
- Accessibility
- Complaints
- Pick-up and delivery
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Medicare
Advantage Implications for RHCs TOP |
Slide 24: Practice management
- What information does the plan require for authorizing
hospital admissions?
- Is it necessary to certify length of stay?
- Are non-covered services defined?
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Medicare
Advantage Implications for RHCs TOP |
Slide 25: Practice management
- How do you handle disruptive patients? Can you discharge
them?
- Are you notified when an enrollee is no longer eligible?
Who pays for treatment if not notified?
- What services does Utilization Review (UR) track?
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Medicare
Advantage Implications for RHCs TOP |
Slide 26: Reimbursement
- How does the fee schedule compare to my usual and customary
charges?
- How does the fee schedule compare to my cost per encounter,
including procedures?
- What is the turnaround time for claims payment?
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Medicare
Advantage Implications for RHCs TOP |
Slide 27: Reimbursement
- If I perform certain labs and/or x-rays
in my office, will I be reimbursed?
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Medicare
Advantage Implications for RHCs TOP |
Slide 28: Contracting Issues
- Negotiate rates - when are rates adjusted?
- Definition of cost/payment
- Year End Settlement
- Vaccine Payment/Influenza/Pneumococcal
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Medicare
Advantage Implications for RHCs TOP |
Slide 29: Contracting Issues
- Medicare bad debt allowance
- Length of contract
- Claims processing UB92 (1452) or 1500
- Time frame for payment of clean claims
- How are rate changes addressed?
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Medicare
Advantage Implications for RHCs TOP |
Slide 30: Contracting
Issues
- How are you paid for non-RHC services?
- How does the plan address RHC services provided by PA/NP/CNM?
- Does the plan cover behavior health services? CP, CSW
- Is credentialing required?
- How do you credential PA/NP/CNM?
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Medicare
Advantage Implications for RHCs TOP |
Slide 31: Contracting
Issues
- How are incidental services such as injections paid for?
- Do co-pays differ for RHC vs. Non-RHC providers?
- Recognize RHC services as separate from Part B; i.e.:
clinic visits, hospital admission same day
- Definition of core RHC services; i.e.: SNF, patients home,
RHC, "Incident-To" services
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Medicare
Advantage Implications for RHCs TOP |
Slide 32: Contracting
Issues
Tracking
data
- Will the plan provide PS&R type of report?
- Visits
- Co-pays
- Deductible
- Payments
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Medicare
Advantage Implications for RHCs TOP |
Slide 33: Contracting
Issues
- Will data report provide break down by provider type for:
- Visits
- Co-pays
- Deductible
- Payments
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Medicare
Advantage Implications for RHCs TOP |
Slide 34: Advice from CAH Administrators
with MA Contract Experience
Administrators
must remember they have the power to negotiate:
- "Stand firm! Don't take anything less than cost-based
reimbursement"
- "Try to negotiate as close as possible to current cost-based
reimbursement"
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Medicare
Advantage Implications for RHCs TOP |
Slide 35: Advice
from CAH Administrators with MA Contract Experience
Administrators
need to read contracts carefully and bring in experts who
understand payment and contract language:
- "Talk to whoever does the cost reports (for your hospital)
and a lawyer who is familiar with this area"
- "Read everything…look at every single detail."
- Watch the language used in the contract, (language) such
as 'sole discretion of payer.'
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Medicare
Advantage Implications for RHCs TOP |
Slide 36: Advice
from CAH Administrators with MA Contract Experience
Administrators
should be sure the contract states specifically the terms
that are required to meet the needs of your hospital.
- "Be clear about time frames for payment and try to get
prompt payment for services."
- "Make sure contract wording includes ability to make rate
adjustments based on CAH cost report rules."
- "Get, or try to get, interim rate updates."
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Medicare
Advantage Implications for RHCs TOP |
Slide 37: Summary
- Negotiate - critical for RHCs not to accept without negotiation
- Giving up cost settlement has value - what are you receiving?
- Be prepared to negotiate the best rate for your RHC. Don't
assume you must accept what is being offered without analyzing
the impact on your RHC.
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Medicare
Advantage Implications for RHCs TOP |
Slide 38: Common Terms
PFFS Private Fee for Service
RPPO Regional Preferred Provider Organization
PS&R Provider Statistical and Reimbursement
Co-Pay Payment required associated with a service.
SNF Skilled Nursing Facility
CP Clinical Psychologist
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Medicare
Advantage Implications for RHCs TOP |
Slide 39: Common
Terms
CSW Clinical
Social Worker
PA Physician Assistant
NP Nurse Practitioner
CNM Certified Nurse Mid-wife
UB92 Part A billing format
1500 Part B billing format
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Medicare
Advantage Implications for RHCs TOP |
Slide 40: Common
Terms
Provider
based RHC is integral part of a provider operated as
a unit of the provider with common systems for management.
Independent
free standing rural health clinic
AIIR All
Inclusive Interim Rate
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Medicare
Advantage Implications for RHCs TOP |
Slide 41: Questions
Email: nelson@hsagroup.net
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