Transcript Document

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
Technical Tips to this Webinar’s Technology
 Polling questions: We will be asking several questions during the course of today’s
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 “Q&A.” Click on it, type in your question, then click on
“Ask.” We’ll 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.
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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 – Don’t know
How many Independent Practice Associations (IPAs) does your center
contract with for Medicaid/FHP?
None – One – Two to three – Four or more – Don’t know
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Agenda
 Overview of the Managed Care Shortfall Payment program
 Managed Care Contracting
 Shortfall Payment Rate Calculation
 Billing Requirements
 MCVR Reporting
4
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 FQHC’s 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.
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Overview of the Program (cont’d)
 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.
6
Overview of the Program (cont’d)
 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.
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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.
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Submission of Qualifying MCO/FQHC Contracts (cont’d)

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.
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Submission of Qualifying MCO/FQHC Contracts (cont’d)
 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.
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Submission of Qualifying MCO/FQHC Contracts (cont’d)
 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.
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Submission of Qualifying MCO/FQHC Contracts (cont’d)
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?
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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
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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-forservice rate base to the PPS rate
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Calculation of the Shortfall Payment Rate (cont’d)
 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
Clinic rate (PPS)
$147.88
PCAP
175.00
HIV enhanced rates
150.00
New
Calculation
$ 147.88
Total Fee-for-service
151.30
147.88
Medicaid managed care
90.00
90.00
$ 61.30
$ 57.88
Shortfall payment rate
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Calculation of the Shortfall Payment Rate (cont’d)
 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.
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Calculation of the Shortfall Payment Rate (cont’d)

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.
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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.
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Criteria for Submitting Supplemental Payment Claims (cont’d)
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.
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Criteria for Submitting Supplemental Payment Claims (cont’d)
 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:
o
o
o
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).
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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)
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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)
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Poll Question 5
For visits covered under capitation arrangements, as indicated on the
remittance advices, do you post the MCO’s approval in your Practice
Management System?
Yes
No
Not Sure
Not Applicable
(No Capitation
Arrangements)
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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
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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).
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MCVR Form and Instructions (cont’d)
MCVR Reporting Form:
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.
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MCVR Form and Instructions (cont’d)

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.
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MCVR Form and Instructions (cont’d)

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.
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MCVR Form and Instructions (cont’d)
 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.
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MCVR Form and Instructions (cont’d)
 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.)
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MCVR Form and Instructions (cont’d)
MCVR Reporting Form:
MCO Name
IPA Name
Medicaid
FHP
Combined
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.
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MCVR Form and Instructions (cont’d)
MCVR Reporting Form:
Calculation of Managed Care Shortfall Payment Rate -
FQHC PPS Rate less Recruitment and Retention:
- Total Average Rate Per Visit:
= Calculated Supplemental Rate:
Enter most current PPS rate
Automatically calculated from Column K,
Line 26
Supplemental rate is subject to verification
and approval of information submitted
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MCVR Form and Instructions (cont’d)
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?
33
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)
34
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)
35
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)
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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.
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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’!
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Questions
39
Contact Information

Kate Breslin, CHCANYS – Director of Policy
[email protected]

Peter R. Epp, CPA, RSM McGladrey – Managing Director
[email protected]

Helen Pfister, Esq., Manatt Phelps & Phillips, LLP – Partner
[email protected]

Scott Morgan – RSM McGladrey – Director
[email protected]

Lynn Sherman, Charles B. Wang CHC – CFO
[email protected]
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