SECTION V. HMO Reimbursement Methodology

Transcription

1 SECTION V. HMO Reimbursement Methodology Overview V-2 SFHN s Financial Responsibility Provider Payment Methodology Chart Primary Care Physicians V-4 Overview Capitated Primary Care Services Services Reimbursed Under Fee Schedule Medicaid Services Reimbursed at 150% of Medicaid Fee Schedule Specialty Care Physicians V-11 Capitated Specialty Care Services SCPs and Fee-For-Service Capitated Services Normally Provided by St. Francis Hospital that SCPs May do in Their Office St. Francis Hospital as a Capitated Provider V-15 Services Covered by Capitation Ancillary Services Directory Carve-Out Services Paid by the HMOs V-22 Copayment Overview V-23 04/28/08 Section V - 1 -

2 ST. FRANCIS HEALTH NETWORK HMO Reimbursement Methodology Overview SFHN s Financial Responsibility St. Francis Health Network negotiates agreements with its HMO payers for a high percentage of the premium the HMOs receive from employers. (The HMO retains a percentage to cover their marketing, enrollment, member services, administrative costs, and a small profit margin.) The percentage of premium received by SFHN is to cover all medical costs incurred by HMO members, with the exception of certain carved-out services that are identified in this Section, and SFHN s administrative/operational costs. SFHN physicians and St. Francis Hospital share in managing the quality and cost of health care for persons who select SFHN for provision of their health care benefits. All SFHN providers agree to accept capitation and/or the SFHN maximum allowable fee schedule with a percentage of withhold on their reimbursement. Return of the withhold to providers is based on each year s incentive plan. A copy of the incentive plan has been mailed to each physician. 04/28/08 Section V - 2 -

3 HMO Reimbursement Methodology Overview Provider Type PCP or PMP Services Performed Routine primary care services Commercial HMOs Payment Withhold Method Full-risk Capitation 10% Medicaid Payment Withhold Method Fee-For- Service (Proprietary Enhanced Fee Schedule) NA Other service typesexamples: General surgery, hospital visits, immunization, after hours care SFHN Fee Schedule 15% Proprietary Enhanced Fee Schedule NA OB/GYN SFHN Fee Schedule 15% Proprietary Enhanced Fee Schedule NA SCP (capitated) SCP (noncapitated) Hospital Referral patient services Referral patient services Hospital Related Services: Shared-risk capitation SFHN Fee Schedule Full Risk Capitation 15% NA NA 15% 100% Medicaid Allowable 10% Full-risk Capitation NA 10% Inpatient Outpatient Ancillary 04/28/08 Section V - 3 -

4 Primary Care Physician Reimbursement SFHN Primary Care Physicians (PCPs) are reimbursed per capitation and the SFHN maximum allowable fee schedule: Primary Care Services Capitated primary care services and the method of reimbursement are identified in this Section. Capitation Check & Report A capitation check and a listing of the members who selected the physician as his/her PCP is mailed to the PCP on the 20th of each month. (See sample enrollee activity statement and capitation report.) PCPs May Bill Fee-for-Service for Designated Specialty Care Services Specialty care services for which PCPs will be reimbursed are identified in this Section. PCPs Must Submit 1500 Claim Forms PCPs are to submit a 1500 claim form for all services covered under capitation or paid fee-for-service. Providing SFHN with a 1500 for capitated services will allow SFHN to track primary care encounters and obtain data for the development of primary care cap rates and utilization reports. Claims are to be submitted within 120 days from the date services were rendered or 30 days after receiving the EOB from the primary payor if payment is to be made. 04/28/08 Section V - 4 -

5 Patient Management Fee Effective January 1, 2001, SFHN PCPs will be paid a patient management fee in addition to the capitation they receive for each patient. The management fee will be paid annually in a lump sum and will be based on a PCP s average number of member months for the year. The formula is as follows: Average Number of Members Months Incentive Paid Per Member Month 600 and over $ $ $ $ $ $0.10 Example: A PCP who has a total of 7,791 member months in a calendar year would have a monthly average of 649 member months (7,791 12). The patient management fee due the physician would be determined by multiplying the 649 average member months by $0.55. This would result in a check for $4,285 being issued to the physician for managing his/her patients during the year. As the physician s number of SFHN patients increases, the amount paid for managing each individual patient increases. 04/28/08 Section V - 5 -

6 COMMERCIAL CAPITATED PRIMARY CARE SERVICES See file: CommercialCapitatedPrimaryCareServices.pdf 04/28/08 Section V - 6 -

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9 MEDICAID PRIMARY CARE SERVICES See file: MedicaidPrimaryCareServices.pdf 04/28/08 Section V - 9 -

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11 Specialty Care Physician Reimbursement Capitated Specialty Care Services Specialty care physicians that have agreed to the capitation method of reimbursement for services provided SFHN commercial HMO members: The capitated specialty care services are: Anesthesia Allergy Cardiology Cardio-Vascular Surgery Colon-Rectal Surgery Emergency Gastroenterology General Surgery OB-Gyn Oncology/Hematology Ophthalmology Orthopedic Surgery Otolaryngology Pathology Plastic Surgery Podiatry Radiology Radiation Oncology Urology 04/28/08 Section V

12 Non-Capitated Specialty Care Services Non-capitated specialty care physicians (SCPs) are reimbursed as follows: Services provided commercial HMO members are reimbursed fee-forservice according to the SFHN maximum allowable fee schedule minus a 15% withhold. Capitated and Non-Capitated SCPs Must Submit 1500s: SCPs are to submit a 1500 claim form for all services covered under capitation as well as for services paid fee-for-service. Providing SFHN with a 1500 for capitated services will allow SFHN to track encounters and gather data for the development of specialty care cap rates and utilization reports. Claims must be submitted within 120 days from the date services were rendered or 30 days after receipt of the EOB from the primary carrier if payment is to be processed. 04/28/08 Section V

13 SPECIALTY CARE PHYSICIAN SERVICES See file: SpecialtyCarePhysicianServices.pdf 04/28/08 Section V

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15 Capitated Services Provided By St. Francis Hospital SFHN manages cost by paying St. Francis Hospital an actuarially determined per-member-per-month amount to provide the following services for SFHN members: Inpatient services Outpatient surgery services Radiology services Laboratory services Outpatient Therapies: Physical, Occupational, Speech Home health care, hospice Skilled nursing facility services Since St. Francis Hospital is prepaid for providing these services, payment to out-of-network providers results in duplication of payment and cost to the network which affects the amount of withhold returned to providers. Exception: Certain services have been pre-approved to be rendered in the capitated specialty offices. Please refer to pages 13 & 14 of this section for additional detail. 04/28/08 Section V

16 St. Francis Health Network Participating Ancillary Providers The St. Francis Health Network ancillary providers are to be utilized for the following services: Service Provider s Name/Address/Phone # Ambulance Service Preferred Provider Behavioral Health/Chemical Dependency Patients may self refer. Biotech/Biopharm Drugs To be administered by the patient, or by physician in his office by Home Health RN, or at St. Francis Hospital Medical or Peds Clinic. Rural/Metro Ambulance (317) Advantage Health Solutions: Midwest Behavioral Health M-Plan, MDwise: Comprehensive Behavioral Care (CompCare) CONTACT: Advantage Health Solutions, MDwise: Medical option 4 M-Plan: MMG Specialty Pharmacy (317) Must be authorized by Specialty Pharmacy Provider. Durable Medical Equipment (DME) Call to request authorization ( ) or fax request form to Home Health Care/Hospice Prior authorization required. Other Info: Chemotherapy Drugs: Subject to SFHN Prior Authorization Policies, may be provided in the physician office.copayments: The Specialty Pharmacy Provider is owed any copayment and will collect it from the patient prior to delivery of the drug. Same Day Delivery: The Specialty Pharmacy Provider has an agreement with an Indiana provider for provision of any biotech drug where same day delivery to your office or the patient s home/work location is required. Please try to order the biotech drug(s) as far in advance of administration as possible. To order authorized equipment: Multiple Contracted Providers SFHN will direct to appropriate provider at the time authorization is given. St. Francis Hospital and Health Centers 438 South Emerson Avenue Greenwood, Indiana (317) (home care) (317) (hospice) 04/28/08 Section V

17 Laboratory (Lab svcs do not require prior authorization) or Call to request specimen pick up at your office Patients register with Hospital Admitting Patients register at ER for outpatient lab tests before being sent to the Clinical Laboratory Patients can register at this draw site Patients register with Hospital Admitting Patients register at this draw site Patients register with Hospital Admitting Patients register at this draw site Patients register at this draw site Patients register at this draw site St. Francis Hospital and Health Centers Outpatient Lab Collection Sites and Hours: Beech Grove Facility Draw Stations West Entrance (317) Monday-Friday 6am-6pm, Saturday 6:30am-3pm After hours Monday Friday, (6 p.m. to 6 a.m.) and weekends, Beech Grove Clinical Laboratory (317) Beech Grove Family Physicians 2030 Churchman Avenue Beech Grove, IN Monday-Friday 8am-4pm (317) , x112 Indianapolis Campus Ambulatory Care Center-Reception Area Monday-Friday 6am-9pm, Saturday 7am-3pm For information, call the Clinical Lab at (317) Indianapolis Campus Professional Arts Building (Rehabilitation Area) 8051 South Emerson Avenue, Suite 100 Monday-Friday 7am-5pm (317) St. Francis Hospital Mooresville 1201 Hadley Road (off the main lobby) Mooresville, Indiana Monday-Friday 6:30am-5:30pm, Saturday 9am- 12pm (317) Physicians Office Building (formerly Family Health Care Center) 8141 South Emerson Avenue Monday-Friday 8am-5pm (317) St. Francis Plainfield Health Center 315 Dan Jones Road Plainfield, IN Monday-Friday 7am-5pm (317) St. Francis-Johnson Memorial Imaging Center (St. Francis Lab Station located within Center) 3147 W. Smith Valley Road, Suite D Greenwood, IN Monday-Friday 8am-8pm, Saturday 8am to 12pm (317) /28/08 Section V

18 Inpatient/Outpatient Care Prior authorization must be obtained for most services by the ordering physician. (See Section III in the SFHN Physicians Office Manual.) Outpatient Physical Therapy And Occupational Therapy The ordering physician is to obtain authorization from SFHN prior to the provision of service. St. Francis Hospital and Health Centers 1600 Albany Street Beech Grove, Indiana Admitting: Inpt , Outpt St. Francis Hospital and Health Centers / Indianapolis Campus 8111 South Emerson Avenue Indianapolis, Indiana Admitting: Inpt , Outpt St. Francis Hospital and Health Centers / Mooresville 1201 Hadley Road Mooresville, Indiana Admitting: Inpatient & Outpatient St. Francis Sports Medicine 700 East Southport Road Indianapolis, Indiana (317) St. Francis Hospital and Health Centers 1600 Albany Street, Ground Tower Bldg. Beech Grove, Indiana (317) St. Francis Hospital and Health Centers Indianapolis Campus 8051 South Emerson Avenue, Suite 100 Indianapolis, Indiana (317) Kendrick Physical Therapy at St. Francis Hospital 1199 Hadley Road Mooresville, Indiana (317) St. Francis Plainfield Health Center 315 Dan Jones Road Plainfield, IN (317) *No Occupational Therapy 04/28/08 Section V

19 Radiology Routine x-rays do not require authorization. MRIs, MRAs and CT Scans do require authorization. Call to schedule at BG & SC locations. Call to schedule at Mooresville. St. Francis Hospital and Health Centers 1600 Albany Street Beech Grove, Indiana St. Francis Hospital and Health Centers / Indianapolis Campus 8111 South Emerson Avenue Indianapolis, Indiana St. Francis Hospital and Health Centers / Mooresville 1201 Hadley Road Mooresville, Indiana St. Francis-Johnson Memorial Imaging Center 3147 W. Smith Valley Road, Ste. D Greenwood, IN (317) St. Francis Plainfield Health Center 315 Dan Jones Road Plainfield, IN (317) *No MRI s or CT South Indy MRI & Rehab Center 8141 South Emerson Avenue Indianapolis, IN (317) South U.S. Highway 31 Indianapolis, IN (317) West Smith Valley Road, Suite D-5 Greenwood, IN (317) /28/08 Section V

20 Rehabilitation Services Prior authorization will be obtained by the patient s case manager. Surgery Centers The ordering physician is to obtain authorization from SFHN prior to the provision of service. Rehabilitation Hospital of Indiana 4141 Shore Drive Indianapolis, Indiana (317) South Indy MRI & Rehab Center 8141 South Emerson Avenue Indianapolis, IN (317) South U.S. Highway 31 Indianapolis, IN (317) West Smith Valley Road, Suite D-5 Greenwood, IN (317) Franciscan Surgery Center 5255 E. Stop 11 Rd., Ste. 100 Indianapolis, IN (317) South Emerson Surgery Center 8141 S. Emerson Ave., Ste. C Indianapolis, IN (317) Indiana Orthopaedic Surgery Center 5255 E. Stop 11 Rd., Ste. 110 Indianapolis, IN (317) /28/08 Section V

21 Urgent Care Urgent care services are to be provided by the PCP during regular office hours within 24 hours of the patient s call. Authorization must be requested by the PCP when the PCP refers a patient to Prompt Care or Prompt Med (Mooresville) after regular office hours. Speech Pathology and Audiology The ordering physician is to obtain authorization from SFHN prior to the provision of service. Skilled Nursing Facility Referral authorization will be obtained by the patient s case manager. Prompt Care of St. Francis Hospital Indianapolis Campus 8111 South Emerson Avenue Indianapolis, Indiana (317) or Prompt Med of St. Francis Hospital Mooresville 1000 Hadley Road Mooresville, Indiana (317) St. Francis Hospital and Health Centers 1600 Albany Street Beech Grove, Indiana (317) Multiple Contracted Providers SFHN will direct to appropriate provider at the time authorization is given. 04/28/08 Section V

22 CARVE-OUT SERVICES Carve-out services are services that are paid by the HMO and are not SFHN s financial responsibility. Any claims related to carve-out services are to be forwarded to the appropriate HMO. Please check the chart to see which services are the HMO s responsibility and which are SFHN s responsibility. Healthcare Services Advantage Franciscan Mental Health/Substance Abuse Midwest Behavioral Health Midwest Behavioral Health Pharmacy Service, Outpatient HMO HMO Vision and Dental Benefits HMO HMO Services that cannot be Provided Pursuant to Catholic Directives HMO HMO Out-of-Area Emergency Services SFHN SFHN Member/ Patient Services Advantage Franciscan Enrollment, Benefit Questions, Grievances, Member Claims Inquiries HMO HMO 04/28/08 Section V

23 SFHN REIMBURSEMENT METHODOLOGY COPAYMENT OVERVIEW A copayment is a specific amount of a physician s charge for an office visit that the member is responsible for paying. HMO members usually have copays for office visits with primary care and specialty care physicians. Members also have copays for urgent care and emergency services provided at Prompt Care, Prompt Med (Mooresville), Priority Care or the St. Francis Hospital ER: SFHN s designated urgent and emergent care facilities. The copayment amount will vary according to the plan and the employer. Look for copayments on members ID cards. If you are uncertain about how much the member is to pay, you may call the HMO Member Service Department to verify the amount. If a member has dual coverage, a copay should not be collected. In general, a member participating in SFHN cannot be billed by the physician s office. However, since the member is responsible for the copay and in some cases, coninsurance, the member may be billed for those amounts. SFHN recommends that the physician s office collect the copayment from the member at the time of service. CPT Code COPAYMENT FOR MID-LEVEL PROVIDERS Effective with February 15, 2002, dates of services, a copay should not be taken on CPT Code The CPT code book definition of CPT reads, Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services. By not taking a copay on we are following coding advisors recommendations and our HMOs copay policies. Office visit copays can be taken for services provided by physicians or nurse practitioners and physician assistants for a 992 code other than SFHN does not yet credential these midlevel practitioners and any services they provide are billed under the supervising physician s name. (Reminder: A copay should never be taken for services provided by LPNs, RNs, CMAs, dietitians, certified diabetes educators, and certified health educators.) 04/28/08 Section V