Ryan White National TA Webinar Fiscal Issues 1
Agenda Announcements Presentation: Monitoring Tools Q-and-A Session I Presentation: Program Income Q-and-A Session II Presentation: Payer of Last Resort Q-and-A Session III 2
Program Income & Related Issues Eli Camhi, MSSW Kathleen A. Wolf, MPA 3
2 National TA Webinars Part A -- April 24, 2012 Part B April 26, 2012 4
Purpose: To present an overview of the requirements for program income and related issues. To present the practical application of the national monitoring standards with respect to program income and related issues. 5
Upon completion of this TA, participants will understand the basic requirements for: Client Eligibility Sliding Fee Scales Client Charges Caps on Charges Payer of Last Resort Program Income Uses of Program Income Tracking Program Income (billing systems) 6
Upon completion of this TA participants will be able to plan for the implementation of the national monitoring standards on program income and related issues by: Developing monitoring questions Identifying documentation to be reviewed in site visits 7
National Monitoring Standards Link to Universal Monitoring Standards: http://hab.hrsa.gov/manageyourgrant/files/univ ersalmonitoringpartab.pdf Link to FAQs re the standards: http://hab.hrsa.gov/manageyourgrant/files/pro grammonitoringfaq.pdf 8
National Monitoring Standards Issued in 2011, effective immediately Help Part A and Part B grantees meet federal requirements for program & fiscal monitoring Consolidate many requirements from statute, regulations, guidance & other sources Applicable to Part A, Part B & MAI funds 9
National Monitoring Standards Require annual fiscal monitoring site visit Site Visit to be standardized by published fiscal monitoring policies & procedures Include protocol Use of monitoring tool or guide Issue monitoring report Grantee to follow up on corrective action plan 10
Monitoring Tools A Few Suggestions 11
Monitoring Tools Organize by sections for each major category Use yes no n/a questions Phrase questions so yes = good No answer not necessarily poor if there is sufficient alternative methodology Reviewer makes thoughtful decisions & uses judgment in monitoring 12
Example: yes = good Does the provider comply with the 10% limit on administrative costs? As opposed to: Are administrative costs greater than 10%? 13
Example Format Monitoring Question Yes No N/A Does the provider actively bill Medicaid? Does the provider track the receipt of income related to the HIV/AIDS program? Does the provider track the use of program income? 14
Client Eligibility 15
Client Eligibility Screening and Reassessment of Clients Intake Forms Reassessments Determined by the EMA, TGA, State or ADAP Reassessment every 6 months for continued eligibility 16
Documentation of Eligibility Proof of HIV Status Labs - Viral Load / CD4 / HIV Testing Primary Care HIV Medication Proof of residence Proof of income 17
Examples of Documentation Income Pay Checks Payments from Public Assistance Self employment income Proof of Residence Utility bills addressed to client s home Rent payments Client Attestation 18
Eligibility Policies No exclusion of veterans living with HIV Inclusion of non-infected co-laterals Accessibility to low-income individuals with HIV Provision of services regardless of an individuals ability to pay for service Provision of services for primary care (not only HIV care) 19
Client Eligibility for Insurance Medicaid Fee For Service Managed Care Medicare Other Coverage Health Homes Patient Centered Medical Homes 20
Suggested Monitoring Questions Does the grantee have policy and procedures on client eligibility? Does the grantee document HIV status for each client? Does the grantee document client annual income? Does the grantee reassess Ryan White and 3 rd party eligibility every 6 months? 21
Sliding Fee Scale 22
Sliding Fee Scales Most programs have sliding fee scale Must permit no charge for < = 100% Federal Poverty Level Establish a policy that addresses this requirement There are no set fee schedules but best practice is to set the scale based on Federal poverty guidelines 23
Bureau of Primary Health Care Patient discounts adjusted on the basis of the patient s ability to pay Full discount to individuals with annual incomes at or below 100% of Federal poverty guidelines 24
Self-Pay & Sliding Fee Scales Patient Registration Accounts Payables Collections expected but not aggressively Caps on Charges Never deny service regardless of the ability to pay 25
U.S. Poverty Guidelines Published Annually in the Federal Register Health and Human Services Posts on the Web http://aspe.hhs.gov/poverty/index.shtml#latest 26
Sliding Fees & Caps Use only the Client s annual income regardless of family size 27
Suggested Monitoring Questions Does the grantee have a sliding fee scale? Are the U.S. Poverty Guidelines utilized? Are they updated annually? Are charges waived for clients with income at or below poverty. 28
Client Charges 29
Client Charges Charges are for HIV and primary care. Charges are not client payments. Payments can be waived by the program. Charges can include medical expense not provided by the program. Client is responsible for providing this documentation. 30
Client Intake Process New Client Intake Captures Client s annual income Referral for Insurance application Eligibility for Sliding Fee Scale Group Patients by Poverty Level Cap on Charges Calculate annual cap on charges Generate monthly reports of patient charges Monitor YTD charges Flag patients who are near cap Stop charges when appropriate 31
Caps on Client Charges 32
Cap on Client Charges Determine cap based on client (not family) income Limit annual patient charges to cap Stop charges once cap is reached Include other patient charges related to medical care Repeat each year 33
Cap Calculator 34
Suggested Monitoring Questions Does the grantee track patient charges? Are charges stopped upon reaching the cap? Is a cap in place for each patient based on the U.S. Poverty Guidelines? Is the client s income reassessed every 6 to 12 months? Is the client s cap recalculated upon change in income? 35
Program Income 36
Applicable Regulations Uniform Administrative Requirements (45 CFR Part 225) OMB Circular A-133 Audits of States, Local Governments and Non-Profit Organizations HHS Grants Policy Statement 37
What is program income? Program income is any income that is generated for a grantee or subcontractor by the grant or earned as a result of the grant. Includes charges to beneficiaries under the sliding scale, as well as reimbursements from Medicaid, Medicare, and private insurance for services provided. 38
RW Program Requirements Providers are required to maximize the service reimbursement available from private insurance, Medicaid, Medicare, and other third-party sources. Providers are required to track and report all sources of service reimbursement as program income on the annual Federal Financial Report and in annual data reports and report on application submitted. All program income earned must be used to further objectives of the HIV program. 39
RW Program Requirements FAQ # 34 Does an agency that receives Ryan White HIV/AIDS Program funding have to be a Medicaid provider? No. The Medicaid provider provision applies only to providers who provide services covered by Medicaid. The Ryan White HIV/AIDS Program legislation, Section 2604(g), describes these as any such service that is available pursuant to the State plan approved under title XIX of the Social Security Act for the State. 40
Tracking Program Income Ideal Tracking System o Budgeted as a resource with plans for specific expenses for which it will be used o Recorded in accounting system designated as RW Program Income o Transactions in accounting system to record specific receipts and specific expenses 41
Tracking Program Income Acceptable Tracking System o Billing system reports show amount collected o Program income is apportioned to programs either in accounting system or summarized on spreadsheet o Compared to administrative cost not covered in RW budget 42
Multiple RW Parts FAQ # 66 If a Part B provider also receives Part C and Part D funding and the client is effectively enrolled in all three parts, which program collects the sliding fee? The agency /program collects the fees based on the services rendered at the time of the visit, regardless of the funding source. The total program income (collected fees) can for the purpose of reporting be apportioned directly or indirectly by formula. 43
Examples of Billing System Reports Tracking Program Income Charges & collections by payer Charges & collections by all patients with HIV/AIDS diagnoses Charges & collection for practitioners whose salaries are paid w/ RW funds # of encounters by payer for all patients w/ HIV/AIDS diagnoses 44
Suggested Monitoring Questions Does provider prepare and review reports on program income? Does the provider use reports on services by practitioner to assess reasonableness of time and effort charged to RW Program? 45
Uses of Program Income Program income can only be used for eligible or allowable costs under the grant. Therefore, program income can be used for primary care, other program services and administrative expenses that would normally be allowed under the grant. Program income may not be used for costs that would not normally be allowed under the grant, such as construction or renovation, vehicle purchase, direct reimbursement to patients or recreational activities for patients. 46
Suggested Monitoring Questions Does the provider budget for program income and monitor budget vs. actual? Is program income recorded in the accounting system by program or activity that generated it? Do fiscal policies specify how program income is tracked by the activity that generated it? Do fiscal policies specify how the program income is to be used? 47
Suggested Monitoring Questions Does provider report program income to the Part A / Part B grantee? If the provider uses program income to cover unfunded administrative costs, does the provider record this in the accounting system or track it on a spreadsheet? 48
Billing & 3 rd Party Reimbursement 49
Examples of Software eclinicalworks Centricity NextGen SOAPWare Practicee Fusion Greenway Medical IDX 50
Suggested Monitoring Questions Does provider use a practice management software? Does the software include modules for Patient registration Scheduling Electronic medical record Encounter forms Billing & accounts receivable Reports 51
Suggested Monitoring Questions Does the provider identify the source of reimbursement for each patient? Does the provider s system allow for more than one source of reimbursement for each patient, e.g., patient has both Medicare & Medicaid? Does the provider s system identify RW patients and the services that are paid with RW funds? 52
Suggested Monitoring Questions Does provider prepare reports on # & type of service to patients with HIV/AIDS diagnosis? Does provider prepare reports on # & type of service to RW patients? Does provider reconcile # of encounters to daily schedule? 53
Suggested Monitoring Questions Does provider use electronic billing? Is billing done at least monthly? Does the provider follow up on denied claims? Does the provider bill for services to self-pay patients? Does the provider make reasonable collection efforts (e.g., requesting payment at time of service, monthly billing, analysis of the cost to collect, etc.) Does the provider have appropriate procedures for handling delinquent accounts (Note: providers should be discouraged from turning delinquent accounts over to collection agencies.) 54
Payer of Last Resort 55
Legislative References Ryan White Part A 2605 Ryan White Part A 2604 FY2011 Part A Program Guidance 45 CFR 74.24 and 92.25 2 CFR 215.24 56
Ryan White Program PLR Policies The Ryan White Program is PLR Providers must ensure that clients meet RW eligibility requirements Providers must ensure that alternate payment sources are pursued before providing Ryan White Program-funded services Part A & Part B grantees must establish and monitor providers procedures to verify and document client eligibility 57
Ryan White Program PLR Policies Providers must document that their clients are screened for and enrolled in benefit programs, including Supplemental Security Income (SSI), Social Security Disability Insurance (SSDI), Medicaid, Medicare, Children s Health Insurance Program (CHIP) and other State health insurance programs Other programs include public housing, drug or mental health treatment or Supplemental Nutrition Assistance Program (SNAP) Income assistance and Temporary Assistance to Needy Families (TANF) 58
Eligibility for Other Publicly Funded Services Services covered by Medicaid, Medicare & other 3 rd party payers o Primary medical care o Behavioral health services o Case management (in some cases) o Oral health services (in some cases) 59
Monitoring PLR Compliance Client level data systems can be used for PLR monitoring Analysis of family size and income data to identify clients whose FPL needs additional documentation Identify clients who may be eligible for Medicaid or other benefits Chart audits with statistically accurate sample sizes, using standardized review tools and trained reviewers Monitoring site visits to review systems 60
Suggested Monitoring Questions Does provider have intake procedures that encourage enrollment in Medicaid, Medicare and other benefits? Does the provider have sufficient understanding of eligibility criteria? Does the provider assist patients to apply for Medicaid, Medicare and other benefits? Does the provider follow up on self-reports of income and insurance? 61