TENNESSEE PRIMARY CARE ASSOCIATION MEDICAID PROSPECTIVE PAYMENT SYSTEM AND SCOPE CHANGE METHODOLOGIES

Size: px

Start display at page:

Download "TENNESSEE PRIMARY CARE ASSOCIATION MEDICAID PROSPECTIVE PAYMENT SYSTEM AND SCOPE CHANGE METHODOLOGIES"

Irma Melton
5 years ago
Views:

Introductions Overview of TN Medicaid Prospective Payment System (PPS)

requirements One time opportunity for past scope changes Crosswalk

1 TENNESSEE PRIMARY CARE ASSOCIATION MEDICAID PROSPECTIVE PAYMENT SYSTEM AND SCOPE CHANGE METHODOLOGIES PRESENTED BY: BKD, LLP AGENDA Introductions Overview of TN Medicaid Prospective Payment System (PPS) How PPS rates are calculated Scope change policy recap and submission requirements One time opportunity for past scope changes Crosswalk from Medicare cost report to Medicaid PPS tool CMS CMS Questions 2 1

Overview of TN Medicaid PPS 3 TENNESSEE MEDICAID PPS Federal law implementing a PPS for state Medicaid payments to RHCs/FQHCs effective January 1, 2001 Medicare, Medicaid & SCHIP Benefits Improvement

2 Overview of TN Medicaid PPS 3 TENNESSEE MEDICAID PPS Federal law implementing a PPS for state Medicaid payments to RHCs/FQHCs effective January 1, 2001 Medicare, Medicaid & SCHIP Benefits Improvement and Protection Act (BIPA) Replaced reasonable cost payment system Established a minimum per visit payment Used the average of each organization s 1999 and 2000 reasonable cost per visit Established methodology for centers opening after 2000 Established an alternative payment methodology (APM), as long as APM resulted in payments =>PPS and agreed to by affected organizations Ongoing rate adjustments for MEI and scope change 4 2

3 TENNESSEE STATE PLAN AMENDMENT (SPA) Original SPA (2001) Initial rates based on 1999 and 2000 cost reports New clinics interim rates based on comparable clinics and final based on cost report Medicaid managed care reconciliation Scope of service change provision (no defined process) Updated SPA (effective 1/1/06) Established an APM Used two most recent cost report on files as of September 30, 2005 Hold harmless provision APM must be at least equal to BIPA PPS rate 5 CALCULATION OF ORIGINAL PPS RATES States given flexibility in methodology TN Medicaid does not require separate cost report filings Medicare cost report used to determine PPS rates Most clinics can have unique rates for the following: Core services (medical, behavioral) Dental Pharmacy Optometry (not currently utilized) Some clinics have one all-inclusive rate It is important for each organization to understand the origin of their individual PPS rate 6 3

4 Scope Change Policy Recap 7 SCOPE CHANGE POLICY RECAP While there was language in the SPA regarding scope change, there were no examples of qualifying events or standard forms for FQHC/RHCs seeking scope change Current policy defines scope change as change in: Type (most common) Intensity Duration (PCMH, change in patient population) Amount Can request a change once per state fiscal year for changes occurred in the previous two state fiscal years 8 4

SCOPE CHANGE POLICY RECAP Must submit detailed description in writing Must result in at least a 5% increase or decrease over two year period Required documentation Medicare cost reports Trial

5 SCOPE CHANGE POLICY RECAP Must submit detailed description in writing Must result in at least a 5% increase or decrease over two year period Required documentation Medicare cost reports Trial balances Depreciation schedules Submission checklist Allocations, reclasses and adjustments Provider questionnaires 9 ONE TIME OPPORTUNITY FOR PAST YEARS Health Centers have a one time opportunity to request scope changes made in previous years Must be submitted by 12/31/17 Must have 2 years of cost reports Supporting documentation required State will make adjustments for costs not allowed for Medicare but allowed for Medicaid (lab, x-ray, etc) State will notify the FQHC within 120 days New rate implemented beginning of next quarter Reconciled to first day of quarter scope change was requested 10 5

6 Crosswalk tool for Medicare cost reports 11 MEDICARE CROSSWALK TOOL Purpose To estimate Medicaid PPS calculation Required data 2 consecutive years of cost reports Trial balances mapped to Medicare cost report Support for reclasses and adjustments CMS vs Medicare cost report was updated for cost reporting periods beginning 10/1/14 and after Significant changes to classifications and allocations Example 12 6

FINAL THOUGHTS Health center management should have a working knowledge of how current PPS rates were calculated Gather historical cost reports and supporting documentation to calculate

7 FINAL THOUGHTS Health center management should have a working knowledge of how current PPS rates were calculated Gather historical cost reports and supporting documentation to calculate potential PPS rate changes resulting from scope changes Populate crosswalk tool Be aware of adjustments differences between Medicare and Medicaid allowable costs Seek help if needed 13 7

8 Glenn Grigsby, CPA // Director // Scott Gold, CPA // Partner // Mary Ann Baker, CPA // Managing Consultant //

Tennessee Change in Scope Policy for FQHCs and RHCs. October 4, 2016

Tennessee Change in Scope Policy for FQHCs and RHCs October 4, 2016 Webinar Overview This webinar will explain Tennessee s new change in scope policy for FQHCs and RHCs. Topics include Definition of a