Colorado Title X Family Planning Program

Transcription

1 Colorado Title X Family Planning Program Cost Analysis/Rate Setting Part 3: Putting It All Together Presented By: Toni Elhoms, CCS, CPC, AHIMA-Approved ICD-10-CM/PCS Trainer Director of Coding/Compliance R.T. Welter & Associates, Inc.

2 2018 Cost Analysis/Cost Setting Webinar recordings are located at:

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4 Learning Objectives Brief recap of information covered in Webinars 1 and 2 Understand how to develop your fee schedule Discuss how to negotiate with health plans Tips for contract negotiations

5 2018 Cost Analysis/Cost Setting Performing a cost analysis/cost setting activity is a Colorado Title X requirement that demonstrates how vendor sliding fee scales are developed. Charges must be based on a cost analysis of all services provided by the project. - US Department of Health and Human Services, Office of Population Affairs

6 2018 Cost Analysis/Cost Setting Allows you to understand the costs associated with your services Make informed decisions about setting appropriate fees for services Negotiate payment and rates with payers Sustainability

7 RECAP Identifying all costs related to family planning/title X services Categorizing costs into defined cost categories Operating Expenses Personnel Expenses Separating expenses by program and only counting FP costs Using estimates Time Study

8 Budget Spreadsheet

9 Family Planning CPT Codes

10 Codes vs. Volume

11 Resource Based Relative Value Scale (RBRVS) Payment $ = Relative Value x GPCI (geographic practice cost indexes) x Conversion Factor Commercial Health Plans: fixed fee schedule roughly based on Medicare fee schedule The RBRVS is updated annually to reflect new and revised CPT codes

12 Medicare Fee Schedule (MFS) Complete listing of maximum fees used by Medicare to pay providers/suppliers on a fee for service basis CMS develops fee schedules annually for physicians, ambulance services, clinical laboratory services, and durable medical equipment prosthetics, orthotics, and supplies. Changes and updated annually

13 Obtaining RVUs and MFS Data

14 Volume = Value

15 JSI FCA Model Cost Report Cost Pool Calculation Procedures to RVU Conversion Utilization Data Report

16 How to use this information Negotiating with payers Share your findings Developing sliding fee scale Analyzing productivity of your providers Adjusting staffing and resources

17 Developing a Fee Schedule Once you conduct the cost analysis and understand your costs, you can develop your fee schedule (or chargemaster) It is your decision as to how you decide to structure or calculate the rates in your chargemaster Set your fees based on your expectations of what you want to be paid When negotiating with commercial health plans, the MFS should always be the bottom

18 Sample Fee Schedule Analysis CPT Code Medicare Fee Schedule Clinic Charge Master % of MFS Health Plan Rate % of MFS Target Rate % of MFS $ $ % $ % $ % $72.81 $ % $80 110% $88 120% $70.10 $ % $77 110% $84 120% $ $ % $ % $ %

19 Sliding Fee Scale Must contain sufficient proportional increments so that inability to pay is not a barrier to services Must be developed using a cost analysis of all services, including clinical, laboratory services, and supplies Charges should be reasonable, fair, and equitable for all clients Must be designed to cover the reasonable cost of providing each service

20 Sliding Fee Scale Required for Title X Family Planning Program All Title X Family Planning services must slide to $0 for clients 100% FPL or below Must include a schedule of discounts for low to moderate income clients Must be updated annually to incorporate most recent FPL guidelines

21 Sliding Fee Scale 5 Code Model

22 How to NEGOTIATING CONTRACTS WITH COMMERCIAL PAYERS

23 Negotiating Contracts with Commercial Payers

24 Questions to Ask Do you need the health plan to direct volume to you? Can the health plan direct volume to you?

25 Tips for Negotiating Fees Start high payers will ask what you want Share that the plan is reimbursing lower than other plans based on your fee schedule analysis Prepare to wait and wait Prepare to negotiate If you are not satisfied with the final offer, consider discontinuing the contracting process

26 Provider Obligations Office hours/after hours care Timely filing Claim submission Non-discrimination Medical records Policy manual Provider directory Collect Co Pay

27 Term and Termination Multi-year term Termination without cause

28 General Provisions Reciprocity Amendment process Indemnification Legal proceedings

29 Unacceptable Provisions Restricted access to fee schedules. Fee schedule applies to non-covered services. Lack of clarification regarding entities with access to contract and discounts. Payer prohibits provider from establishing panel limits and practice parameters. Any reference to most-favored-nation. Nonstandard coding, billing, or claims submission requirements. Cumbersome (or manual) referral or prior authorization process. Timely filing less than 90 days. Health plan able to amend the contract without your signature.

30 Contracting and Credentialing are ONGOING Processes stay active, stay engaged in this process Review contracts and fee schedules at least every 2-3 years

31 How to Conduct the Cost Analysis Allocate all expenses to the appropriate cost categories associated with the delivery of service 1. Collect cost data and allocate costs to FP 2. Collect Relative Values for services FP provides 3. Collect utilization data on all FP services 4. Determine cost of each service and establish fees based on this information

32 Helpful Reminders You may use any form of cost setting that is appropriate for your setting as long as it can demonstrate how fees are determined on the sliding fee scale

33 Helpful Reminders If your organization has recently updated its cost setting activity, it must have been done in the last 12 months! April 2017 April 2017

34 Helpful Reminders CDPHE is here to help you! CDPHE Contact for Cost Setting?s: Jody Camp Family Planning Unit Section Manager

35 March 2018 Cost Analysis Timeline 3 (1 hour) web-based training webinars on cost setting Every Monday from 12-1pm Cost Setting Budget Template Distributed You may use any form of cost setting that is appropriate for your setting. Cost Setting Summary Uniform Template Distributed

36 Sample Budget

37 Cost Setting Summary Uniform Template

38 Cost Setting Summary Uniform Template

39 Cost Setting Summary Uniform Template

40 April 2018 Cost Analysis Timeline Cost Setting/Cost Analysis process Technical Assistance calls with RTW 30 minute phone consultation and coaching regarding how to perform the cost setting/cost analysis for your organization RTW cannot do your cost analysis Submit your cost analysis to CDPHE by May 1 st

41 2018 Cost Analysis Timeline Technical Assistance Contacts: Todd RTWelter tw@rtwelter.com Toni RTWelter tmw@rtwelter.com

42 May 2018 Cost Analysis Timeline Cost Analysis is due by May 1 st RTW will review cost analysis for each organization and provide necessary feedback We may call to ask questions or get more information from you All cost setting activities and updated sliding fee scales must be completed, potentially edited and approved by May 31 st Contracted activity with OPA and Title X and must be completed this fiscal year.

43 QUESTIONS? 3/19/

44 On Behalf of RTWelter & Associates 3/19/