UC SF Medical Group & Medical Center Active Contracts Report and LOA Training

Transcription

1 UC SF Medical Group & Medical Center and LOA Training April 18, 2012

2 Agenda Letter of Agreement (LOA) Questions 1

3 2

4 Health Plans 3

5 Health Plans Column A contains all of the Health Plans that are contracted with UCSF Medical Center and UCSF Medical Group. 4

6 Contracted Entities 5

7 Contracted Entities Column B thru Column E designate which entity is contracted. 6

8 Contracted Entities UCSF designates the UCSF Medical Center (the hospital and facility fees). When there is UCSF in Column B, it means that row shows with which products UCSF Medical Center is contracted. 7

9 Contracted Entities MG designates the UCSF Medical Group (the physician fees). When there is MG in Column C, it means that row shows with which products UCSF Medical Group is contracted. 8

10 Contracted Entities Other designates an atypical contract. When there is a X in Column D, it means that row shows a contract that is different from our usual Medical Center and Medical Group contracts. 9

11 Contracted Entities For example, cell D50 has an X in it and shows that there is a special pathology only contract with California Pacific Pathology Group. 10

12 Contracted Entities TX Only designates a Transplant Only contract. When there is a X in Column E, it means that row shows a contract for transplants. 11

13 Commercial Plans 12

14 Commercial Plans Column F thru Column K show with which Commercial Plans UCSF is contracted. 13

15 Commercial Plans HMO Cap means HMO Capitation and reflects when an entity is capitated for HMO business. 14

16 Commercial Plans HMO FFS means HMO Fee-for-Service and designates when the Medical Center and/or the Medical Group are contracted for the HMO plan. 15

17 Commercial Plans POS Cap means POS Capitation and reflects when an entity is capitated for POS business. 16

18 Commercial Plans POS FFS designates when the Medical Center and/or the Medical Group are contracted for the POS plan. 17

19 Commercial Plans PPO designates when the Medical Center and/or the Medical Group are contracted for the PPO plan. 18

20 Commercial Plans EPO designates when the Medical Center and/or the Medical Group are contracted for the EPO plan. 19

21 Medicare Plans 20

22 Medicare Plans Column L thru Column P show with which Medicare Plans UCSF is contracted. The first four Plans (HMO Cap, HMO FFS, POS Cap, and POS FFS) all mean the same thing as they did for the Commercial Plans. 21

23 Medicare Plans A Medi-Gap policy (also called Medicare Supplement Insurance ) is private health insurance that s designed to supplement original Medicare. This means it helps pay some of the health care costs ( gaps ) that original Medicare doesn t cover (like copayments, coinsurance, and deductibles). 22

24 Medi-Cal Plans 23

25 Medi-Cal Plans Column R thru Column T show with which Medi-Cal Plans UCSF is contracted. 24

26 Medi-Cal Plans Medi-Medi means Medicare-Medi-Cal and is when a patient has Medicare as primary and Medi-Cal as secondary insurance. 25

27 Medi-Cal Plans HMO FFS stands for HMO Fee-For-Service and is a managed Medi-Cal plan. 26

28 Medi-Cal Plans Hlth Fam FFS stands for Health Family Fee-For- Service and is a managed Medi-Cal plan for the Healthy Family product. 27

29 Additional Information 28

30 Additional Information Column U thru Column Y provide additional information about the contracts. 29

31 Additional Information Column U provides additional miscellaneous information about the contracts. 30

32 Additional Information Column V shows the Original Effective Date, which is the date the contract was originally signed. 31

33 Additional Information Column W shows the most recent Amendment Effective Date of the contract. 32

34 Additional Information Column X and Y give the last name and phone number of the Contracting Contact responsible for each contract. 33

35 What happens when a patient wants to schedule an appointment and has an insurance that is not on the? After an authorization is obtained from the Payor a Letter of Agreement can be requested from The Individual Deal Desk in Health Plan Strategy & Contracting or Katie Terry, Contract Manager for the Medical Group. 34

36 Letter of Agreement (LOA) 35

37 Letter of Agreement A Letter of Agreement is a patient specific contract between a non-contracted Payor and UCSF Medical Center and/or UCSF Medical Group. 36

38 Letter of Agreement A Letter of Agreement is required for all noncontracted Payors, with the following exceptions: Payor is a PPO* and out-of-network benefits are sufficient (e.g. out-ofpocket expense met, deductible, etc.). *UCSF will negotiate with PPO Payors if/when a PPO Payor requests to negotiate. Product is Workers Compensation. UCSF does not do individual deals for Workers Compensation. Advise caller that Payor must pay according to the California Workers Compensation fee schedule. Payor is secondary. UCSF does not do individual deals for secondary Payors. Medical Savings Plans Most will be paid by the health plan; however, if not, then the patient must be self-pay and should be referred to financial counseling. 37

39 Letter of Agreement The following tasks need to be done prior to requesting a LOA: Verify Eligibility and Benefits Obtain an Authorization The LOA should be requested by a Supervisor or a Supervisor should be carbon copied on the . If a Payor will not agree to our minimum pricing guidelines, we will not execute a LOA and Chair approval is required before the patient can be seen. 38

40 Letter of Agreement Out-of-State Medicaid These steps need to be taken before requesting a LOA for an Out-of-State Medicaid patient: Verify Eligibility and Benefits Chair Approval Required Physician Enrollment in Out-of-State Medicaid Plan Prior Authorization 39

41 Letter of Agreement To Request a LOA Do One of the Following: For Professional Fee LOAs: Fill Out a LOA Request Form and send it to Katie Terry via to terryk@ucsfmg.ucsf.edu or fax it to For Facility Fee LOAs: Notify the Individual Deal Desk in Health Plan Strategy & Contracting at and provide the following information: o o o o o o o Patient s name Date of birth Social Security number Name and phone number of office representative that will conduct the negotiation with HPS Diagnosis and procedure Length of stay Medical Service 40

42 Questions? 41