CPSP Reimbursement Models

1. CPSP Reimbursement Models PSC Annual Meeting November 7, 2012

2. Reimbursement Models • Fee-For-Service • Federally Qualified Health Centers (FQHC) /Rural Health Centers (RHC) • Medi-Cal Managed Care

3. Fee-For-Service • Use Z Codes (HCPCS) • Get bonuses • Early entry into care - $56.63 • 10th antepartum visit - $113.26 • Case coordination (in Z6500) - $85.34 • CPSP support services can be provided alone or on same day as medical visit

4. Fee-For-Service • Bill using regular Medi-Cal Claim Forms • Submit bills to Xerox • Reimbursed M/C maximum allowances

5. Fee-For-Service • Individual Services – 23 hours total • Client Orientation, assessments, and reassessments, interventions • Reimbursed at $33.64/hr • Group Classes – 27 hours total • Optional • Reimbursed at $11.24/pt/hr • Lesson plans and sign-in sheets required

6. Fee-For-Service • Adhere to service limits • Track units using Billing Summary or other tool • Submit Treatment Authorization Request (TAR) to Medi-Cal Field Office for support services that exceed limits (not Ob visits)

7. FQHC • Bill only one visit (encounter) per day • Exceptions: • Patient has unrelated illness that same day • Dental visit • Visit defined as face to face encounter with a qualified practitioner plus incidental services

8. FQHC • Bill using 01 for all services (not Z-codes) • Reimbursement is prospective payment system • No early entry or case coordination • Eligible for 10th antepartum visit

9. FQHC • Held to same service limitations as FFS • Need to use M/C Billing Summary or other tool for tracking services by unit • Do not need to submit TAR to Field Office • Document medical necessity for additional units in medical record • Follow instructions for TAR in M/C Manual

10. FQHC Pitfalls • Bill excessive units and Ob visits because “we get paid” • Since they bill 01 for everything, computer doesn’t deny any services • Can be asked for reimbursement if audited • Divide services inappropriately • Can only bill one patient in a group class (= one “encounter” with practitioner)

11. Medi-Cal Managed Care What is the Perinatal Services Coordinator’s Role in Managed Care?

12. Medi-Cal Managed Care • Inform the providers about CPSP in managed care • Collaborate with health plan liaisons: follow MOU and/or subcontracts

13. What to Tell Providers • MCMC patients are entitled to all CPSP services as described in Title 22 regulations • Don’t need to be CPSP-certified, unless required by managed care contract • Benefits of being a provider

14. What to Tell Providers • READ THE CONTRACT! • CPSP is a managed care benefit • All managed care enrollees eligible • Reimbursement method varies by contract • Capitation or separate fee-for-service rate • Cannot bill Medi-Cal for managed care clients • May need prior authorization for high risk referrals

15. FQHCs & Managed Care • FQHCs bill the health plan first for their contracted rate • Bill M/C for the difference between their contract rate and prospective payment rate

16. MCMC Collaboration • Meet quarterly or as directed by contract • Joint trainings, as requested • Be the “CPSP expert” for managed care staff • Collaborative opportunities and expectations may vary depending on type of MCMC (GMC, COHS, Two-Plan)

17. Contact Information Joanne Roberts, PSC Los Angeles County (213) 639-6427 jroberts@ph.lacounty.gov