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FQHC/RHC Enhancement into Managed Care Rates April 16, 2014

FQHC/RHC Enhancement into Managed Care Rates April 16, 2014. Today’s Topics. Brief recap of first webinar and information available Reconciliation overview Reconciliation process Reconciliation data Upcoming webinar session

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FQHC/RHC Enhancement into Managed Care Rates April 16, 2014

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  1. FQHC/RHC Enhancement into Managed Care Rates April 16, 2014

  2. Today’s Topics • Brief recap of first webinar and information available • Reconciliation overview • Reconciliation process • Reconciliation data • Upcoming webinar session • Requests for additional sessions on specific topics (e.g., correct submission of rosters, etc..)?

  3. Brief Recap of Last Week’s Information • Implementation set for June 1, 2014 • Contract language includes language for MCOs ready to make full encounter payments beginning in June • All MCOs are ready and have the capability and experience with this type of payment • Webinar available at: http://www.hca.wa.gov/medicaid/provider/Pages/webinar.aspx

  4. Reconciliation Overview and Process

  5. Reconciliation Process after June 1, 2014 • HCA performs quarterly reconciliation with analysis based on MCO encounter data; encounter data will be shared with the clinics • Reconciliation will be a “rolling” process: • Allows for timelines to be met • Allows for any claims not captured in the current quarter to be captured in the following quarter with no risk of duplicate claim capture • Specific data logic outlined on handout • Each reconciliation allows for timely adjustment to enhancement rates as needed • Lowers future risk of large pay-backs in future quarters/reconciliations • Allows process to get closer to common goal of paying full encounter rate for qualifying services and clients • Appeals process is not changing from the current appeals process

  6. Reconciliation Data beginning June 1, 2014 • Logic for counting encounters has two changes from logic currently used: • Denials will not be reversed • Fee-for-service equivalent will be used only in reconciliations for clinics with capitated agreements; otherwise actual encounter data submitted by the MCOs to HCA will be used • Otherwise encounter logic remains unchanged • Qualifier for managed care claims in reconciliation based on taxonomy • RHC taxonomy – 261QR1300X • FQHC taxonomy – 261QF0400X • No change to how global visits are reported; the only change is related to when global visits are reported for any one client • Delivery case rate enhancement revenue will be included in each clinic’s total revenue • Delivery case rate enhancements are not otherwise changing

  7. HCA Contact InfoOffice of Rates Development Please direct questions regarding this process to: Melissa Usitalo – Encounter Payment Manager melissa.usitalo@hca.wa.gov All other program-related questions should continue being sent to: FQHCRHC@hca.wa.gov General questions on professional rates should be sent to Unit Manager Madina Cavendish: madina.cavendish@hca.wa.gov

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