Medicare FQHC Billing Changes How will it affect you?
Overview – What we’ll cover • Why Medicare is changing • When will it change? • Medicare now • What is changing? • What isn’t changing? • Examples of the new PPS Logic • Outbound claim • Setup Changes in VisCHC • How to prepare
The only constant is change Why it’s changing
Times… they are a changin’… • The Affordable Care Act of 2010 mandated the implementation of a Medicare Prospective Payment System (PPS) to replace the current method of reimbursement for FQHCs • The ACA also broadened the scope of preventive services provided to Medicare patients in FQHCs by fully covering preventive services (no coinsurance required for the patient) • Analysis was based on two data sources: • Medicare Cost Reports • Medicare Claims (18 month sample) • 5,223,512 per diem encounters used
Prospective Payment System (PPS) • PPS - A method of reimbursement in which Medicare payment is made based on a predetermined, fixed amount. • The payment amount for a particular service is derived based on the classification system of that service. • Type, intensity and duration of services were considered
Medicare populations in FQHCs • Federally Qualified Health Centers (FQHCs) were established in 1992 • According to the 2012 Uniform Data System (UDS) Report results: • 1,198 FQHCs with more than 8,900 treatment sites • 83.8 million clinic visits • approximately 9% of the FQHC clientele are Medicare recipients
When will it change? The date an FQHC will begin operating under the PPS Billing Rules depends on their Cost Reporting Start Date.
When will it change? The date an FQHC will begin operating under the PPS Billing Rules depends on their Cost Reporting Start Date. Note: Make sure you’ve provided your site’s Cost Report Start Date to Visualutions
Part A or Part B? That is the question* PART A • Face-to-Face encounters and services with a qualified FQHC core practitioner • Professional Services/Components (EKG interpretation) • SNF visits, home visits, etc. PART B • CLIA-Waived Labs • Technical Services/Components (EKG machine) • In-patient services *List is not exhaustive
How FQHCs are paid now: • Medicare payment system for FQHCs is currently based on an All-Inclusive Rate (AIR). Consists of: • All allowable costs associated with a visit (services, supplies, overhead, etc.) • Rate is subject to upper payment limits (UPLs) which differ for urban and rural areas as well as productivity standards • The rate is adjusted yearly based on the Medicare Economic Index (MEI)
Revenue Codes that count for AIR 09XX – Mental Health Services & 0519 – Medicare Advantage (Wrap)
Patient Responsibility – Medically Necessary Visit • No deductible • Coinsurance calculation: 20% of FQHC’s Charge Amount • Behavioral Health was handled differently – not covering in this session • Other categories: Medical Nutrition Therapy (MNT) and Diabetes Self-Management Training (DSMT)
Patient Responsibility – Preventive Medicine • No coinsurance (or deductible) on Preventive Medicine services since January 2011 • Calculations for coinsurance became trickier on claims with “mixed” codes • Math on claims became trickier
Part A - General • Type of Bill of 771 • Submit all HCPCS/CPT Codes and their appropriate Revenue Codes • Cannot use these Revenue Codes: • 002X-024x, 029x, 045x, 054x, 056x, 060x, 065x, 067x-072x, 080x-088x, 093x, or 096-310x.
Part A Calculations Quiz • Charge Amount: $72.00 • Encounter Rate: $108.81 What is the patient coinsurance amount? 20% of the CHARGE Amount $72.00 x 20% = $14.40
Part A Calculations Quiz • Charge Amount: $72.00 • Encounter Rate: $108.81 • Patient Coinsurance $14.40 What will Medicare Part A Pay? 80% of the ENCOUNTER Rate $108.81 X 80% = $87.05
Part A Calculations Quiz • Charge Amount: $72.00 • Encounter Rate: $108.81 • Patient Coinsurance $14.40 • Medicare Payment $87.05 What is the adjustment amount? (Charge x 80%) – Medicare Payment $72.00 X 80% = $57.60 $57.60 - $87.05 = $-29.45
Part A Calculations Quiz • Charge Amount: $72.00 • Encounter Rate: $108.81 • Patient Coinsurance: $14.40 • Medicare Payment: $87.05 • Adjustment Amount: $-29.05
The 2014 PPS Rate • For 2014/2015, the national PPS Rate is: $158.85 • For the first year, the PPS should equal, “100% of the estimated amount of reasonable costs…that would have occurred for such services under this title in such year if the system had not been implemented.”
The PPS Rate • January 2016: increase based on the Medicare Economic Index (MEI) • January 2017: CMS may implement an FQHC-specific inflationary index reflecting the typical market basket of services provided in the FQHC. If not, then updated via MEI.
Two other factors that affect rate • The Geographic Adjustment Factor (GAF) • Depends on location of FQHC • The New Patient Adjustment Factor • National: 1.3416 • New patients (not received services from any site or practitioner within the FQHC organization within the past 3 years) • Initial Preventive Physical Exam (IPPE) • Annual Wellness Visit (AWV) • initial or subsequent
G-Codes and their Revenue Codes 0519 = Supplemental (Medicare Advantage) 052x = FQHC Clinic, Home, SNF, NF, Scene of Accident, etc. 0900 = Mental Health Treatment Services
What is the reimbursement? • Medicare/Patient payment for a visit will be an 80/20 split of the site’s “actual charge” (for the G-Code) or the PPS Rate – whichever is less • Designed to cover reasonable costs of operation • Behavioral Health services now reimbursed like medically necessary services. Mainstreamed.
G-Code Pricing • CMS does not dictate G-Code charge amounts • G-Code pricing guidance: “would reflect the sum of regular rates charged to both beneficiaries and other paying patients for a typical bundle of services that would be furnished to a Medicare beneficiary”. • “what would be appropriate for the services normally provided and the population served and the description of services associated with the payment code”.
Same Day Services – what is changing • The following are NOT allowed to be billed on the same day: • DSMT or MNT and another billable visit • IPPE and another billable visit • This may require a change in your policies to avoid loss of revenue • All services rendered for a single patient must be submitted on one claim. • Multiple claims will be rejected
What isn’t changing • No coinsurance on preventive medicine services • Services filed to Part A and Part B will not change • Cost Reports are still required. • DOS before Cost Report Date will need to be filed the AIR way.
What isn’t changing • Influenza and Pneumococcal vaccines reimbursed via Cost Report • Timely filing rules • 77X Type of Bill • Items excluded from FQHC rate still excluded (ex: inpatient hospital)
Same Day Services – what isn’t changing • The following are allowed to be billed on the same day: • Medical and BH Visit • Subsequent illness or injury on same day as another medically necessary visit. • Ex: Sore throat then laceration later in the day • Use modifier 59
On Claims: • Must file HCPCS codes on the visit • Includes influenza and pneumonia vaccines and administration • Diabetes Self-Management Training (DSMT) and Medical Nutrition Therapy (MNT) services are subject to frequency edits and should not be reported on same day.
Arizona’s Geographic Adjustment Factor • Arizona’s GAF is .995 for 2014 • PPS Rate X GAF = Adjusted GAF $158.85 x .995 = $158.05 • New Patient or IPPE/AWV Adjustment Factor is 1.3416 (nationally) • AZ’s Adjusted GAF x 1.3416 = $212.04
Routine Medical Visit – Est. Which is less: G Code Charge or site’s PPS Rate?
Routine Medical Visit – Est. $150.00 x 80% = Medicare Payment $150.00 x 20% = Patient Payment
Routine Medical Visit – Est. Which is less: G Code Charge or site’s PPS Rate?
Routine Medical Visit – Est. Use chart below if PPS Rate lower than G code charge
Mental Health Visit – New Which is less: G Code Charge or site’s PPS Rate?
Mental Health Visit – New $200.00 x 80% = Medicare Payment $200.00 x 20% = Patient Payment