Understanding Enhanced. Grouping Implementation EAPG. October 2, 2017

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1 Understanding ing Implementation Understanding ing Implementation

2 Objectives Implementation Scope of Payment Method Pricing Methods Impacts of Helpful Resources Q&A Understanding ing Implementation

3 IMPLEMENTATION: JULY 01, 2017 The Florida Legislature has mandated that the Agency for Health Care Administration (Agency) implement a new outpatient payment method utilizing 3M TM ing () effective for dates of service on and after July 01, This payment method will be used for recipients in the Medicaid fee-for-service program, and may be used by Statewide Medicaid Managed Care (SMMC) health plans. payment methods involve classifying outpatient visits and then determining a price based on a combination of the classification of the outpatient visit and the provider at which the services were performed. The classifications are labeled using codes referred to as codes. Understanding ing Implementation 3

4 Scope of Payment Method Understanding ing Implementation

5 Scope of Payment Method Applicable Types of Providers The payment will be applied to hospitals (PT 01) and ambulatory surgical centers (ASCs- PT 06). Free-standing laboratories (PT 50) and free-standing dialysis centers (PT 89) will be carved out of payment and will continue to be paid via a fee schedule. Federally Qualified Health Centers (FQHCs- PT 68) and Community Health Departments (CHDs- PT 77) will also be excluded from the payment method and will continue to be reimbursed using the current method. Understanding ing Implementation 5

6 Scope of Payment Method Applicable Medicaid Recipients Medicaid Fee-for-Service Transition to payment is only required for the Medicaid fee-for-service program. Applicable services provided to Medicare/Medicaid dually eligible recipients within Medicaid fee-forservice will continue to pay using the lower of the Medicare allowed amount and Medicaid allowed amount. Medicaid allowed amount will be determined using s. Statewide Medicaid Managed Care (SMMC) Health plans are required to submit procedure codes on the detail level. Health plans are not required to change outpatient reimbursement methods. Understanding ing Implementation 6

7 Scope of Payment Method Impacted Services Included in Pricing All services provided in an ambulatory setting, including lab, pathology, therapy, and medications, are included unless carved out. Excluded in Pricing Transplant cases: Global transplant fee will remain in use Reimbursement levels will not change Understanding ing Implementation 7

8 Scope of Payment Method Dates of Service Hospital outpatient and ASC payments are based on the date of service. The earliest date of service indicated on the claim will be used to determine the payment method on claims covering multiple dates of service. Providers should anticipate a transitional period in which both payment methods, and current, will be reflected in payments and appear on providers remittance advices as is dateof-service driven. Understanding ing Implementation 8

9 Scope of Payment Method The Annual Cost Settlement Process An payment will be a prospective payment for outpatient stays and is intended to be payment in full. There is no need for subsequent cost settlement. Post-payment cost settlement of outpatient claims will be phased out over the next few years for hospitals reimbursed via the payment method. Understanding ing Implementation 9

10 Pricing Methods Understanding ing Implementation

11 Pricing Methods allowed amount is determined by combining: The classification of the outpatient visit and The classification of the provider where the services were performed and The relative weight and The discounting factor Understanding ing Implementation 11

12 Pricing Methods Classifications are labeled using codes which have an assigned relative weight. Outpatient visit classifications are based on: Detail line procedure codes and modifier Diagnosis codes (for medical visits) age gender Understanding ing Implementation 12

13 Characteristics of Payment pricing will be used for all services provided in an ambulatory setting including: lab, pathology, therapy, and medications, unless carved out by Florida Medicaid. Prices are determined by classification based on a combination of the type of outpatient visit, the services provided, and the location where the services were provided. Each detail line is assigned its own code. Thus, a separate allowed amount is determined for each service line. Each code is assigned a relative weight intended to indicate the average relative amount of health care resources required to perform that service. A procedure billed on one service line may affect an allowed amount for another service line through packaging, consolidating, and discounting. Understanding ing Implementation 13

14 Pricing Methods Base Payment Calculation For all outpatient detail lines, base payment is calculated using the following formula: Provider Base Rate Relative Weight Provider Policy Adjuster Discounting Factor Base Payment NOTE: Units of service do not affect payment under pricing. Understanding ing Implementation 14

15 Pricing Methods Provider Base Rate The Agency will determine initial base rates for active hospitals and ASCs. The rates will be established for the fiscal year 2017/2018 implementation. Hospitals and ASCs will have different base rates. Base rates can be found on the Agency s website ( under Institutional Rates. Provider Base Rate Relative Weight Provider Policy Adjuster Discounting Factor Base Payment Understanding ing Implementation 15

16 Pricing Methods Relative Weight relative weight is determined after an code is assigned to a claim. The weight shows the relative amount of resources that the treating hospital/asc used to perform services for patients in a specific category. National relative weights determined by 3M Health Information Systems (HIS) will be used. The lowest relative weight is 0, while the highest relative weight is Provider Base Rate Relative Weight Provider Policy Adjuster Discounting Factor Base Payment Understanding ing Implementation 16

17 Pricing Methods Provider Policy Adjuster Provider policy adjusters are numerical multipliers intended to help protect access to care for specific services and/or providers by increasing payment. These adjusters may also reduce reimbursement, if reimbursement is unusually high, versus pre- payment levels for a particular service or category of hospital. Provider adjusters are planned for rural hospitals and hospitals with high Medicaid outpatient utilization. Provider Base Rate Relative Weight Provider Policy Adjuster Discounting Factor Base Payment Understanding ing Implementation 17

18 Pricing Methods Discounting Factor There are three discounting scenarios for pricing. Discounting scenario 1: Payment for some services are packaged and consolidated with payments for other services in the payment method. The discounting factor is set to 0 when services are packaged and consolidated. Provider Base Rate Relative Weight Provider Policy Adjuster Discounting Factor Base Payment Understanding ing Implementation 18

19 Pricing Methods Discounting Factor Discounting scenario 2: Services may be discounted if deemed to be clinically similar to other services billed for in the same visit. The service with the higher relative weight receives full payment when two clinically similar services are provided. Payment for the similar service is discounted to 50%. Provider Base Rate Relative Weight Provider Policy Adjuster Discounting Factor Base Payment Understanding ing Implementation 19

20 Pricing Methods Discounting Factor Discounting scenario 3: payment method performs discounting for bilateral procedures and terminated procedures.* Discounting for bilateral procedures is planned at 150%. Discounting for terminated procedures is planned at 50%. *Modifiers 52 and 73 indicate that the procedure was terminated. Provider Base Rate Relative Weight Provider Policy Adjuster Discounting Factor Base Payment Understanding ing Implementation 20

21 Individual Recipient Annual Benefit Limit The Medicaid fee-for-service $1,500 annual benefit limit per recipient for hospital outpatient service will continue under the payment method. Current exceptions to this limit, including children under 21 and specific revenue codes, will continue to be situations for which the benefit limit does not apply. Annual hospital outpatient benefit limits for recipients in the SMMC program are determined by contracts between the health plan and hospital. Understanding ing Implementation 21

22 Fee-for-Service Payments fee-for-service payments are calculated using the following formula: Base Payment Adjustment Based on Benefit Limit Payment Understanding ing Implementation 22

23 Automatic Rate Enhancement Requirements Service Line Allowed Amounts are calculated using this formula: Base Payment Automatic Rate Enhancement Service Line* Allowed Amount *Automatic *Automatic rate rate enhancement enhancement payments payments will will be be applied applied to to each each paid paid service service line, line, even even if if the the method method bundles bundles payment payment for for that that service. service, or the annual benefit limit is applied to the payment. Understanding ing Implementation 23

24 Impacts of Understanding ing Implementation

25 Changes in Billing Procedures Changes to Outpatient Billing Procedures All services for a single outpatient visit must be billed on one claim submission For hospitals, a procedure code must be submitted along with the revenue codes identified on the Federal Registry NOTE: The Federal Registry will be made available on the CMS website at the following URL: Understanding ing Implementation 25

26 Procedure Modifiers Affecting Payment in Florida Medicaid Implementation These include: 25: Distinct Service Allows payment of a medical visit on the same claim/day as a significant procedure 27: Multiple Evaluation and Management Encounters Allows payment of additional medical visit/services ancillary 50: Bilateral Procedure Flags a procedure for additional payment (150%) 52 & 73: Terminated Procedure Flags a procedure for discounting (50%) 59, XE, XS, XP, & XU: Separate/ Distinct Procedure Allows separate payment of a significant procedure (turns off consolidation) GN, GO, & GP: Distinct Therapy Procedure Modifiers Allows separate payment of a significant procedure (turns off consolidation) Understanding ing Implementation 26

27 Procedure Modifiers Not Affecting Payment in Florida Medicaid Implementation These include: E1- E4 F1- F9 FA LT RT T1- T9 TA RC RI LC LM LD Understanding ing Implementation 27

28 Multiple Dates of Service Claims may continue to be billed with multiple dates of service. Each date of service will be treated as separate outpatient visits unless the claim contains Emergency Department or Observation revenue codes. If a claim contains Emergency Department ( ) or Observation ( ) revenue codes, then the claim will be treated as a single outpatient visit even if multiple dates of service are included. Understanding ing Implementation 28

29 Prior Authorizations for Hospital Providers Prior Authorization Process There will not be any changes made to methods hospitals will use to obtain outpatient prior authorizations (PAs). After the implementation of, hospitals billing for an outpatient procedure(s) that require a PA will need to include a PA number on the outpatient claim submission. If there are multiple PAs, one PA number must be included on the claim, and any additional PAs will be systematically located. If hospitals do not include a valid PA on the claim and/or if there are one or more details that require a PA on the claim, the details that need a PA will be denied for no PA billed using the current edit. Understanding ing Implementation 29

30 X Transaction and Remittance Advices The code, relative weight, and discounting factor assigned to each claim detail line will appear on electronic X transactions and on remittance advices (RAs). Relative weight and discounting factors may not populate on July 1 st, but will soon after. Electronic Loop Service Payment Information: REF Service Identification REF01 = 1S (APG) Number REF02 = Number describing the Code QTY Service Supplemental Quantity QTY01 = ZK Federal Medicare/Medicaid Payment Mandate Cat 1 QTY02 = Number describing the Full Weight QTY Service Supplemental Quantity QTY01 = ZL Federal Medicare/Medicaid Payment Mandate Cat 2 QTY02 = Number describing the Payment Percentage Understanding ing Implementation 30

31 X Transaction and Remittance Advices Remittance Advices: Understanding ing Implementation 31

32 Helpful Resources Understanding ing Implementation

33 3M TM SUPPORT The new outpatient payment method utilizes 3M TM ing () for Medicaid. More information can be found on the 3M TM website: Understanding ing Implementation 33

34 on the Agency Website information can also be found on the Agency s website: To access the information, click on the tab titled Medicaid. Understanding ing Implementation 34

35 on the Agency Website Once on the Medicaid page, scroll down. In the table, navigate to the left column titled Looking for information on. Click on Institutional Rates. Understanding ing Implementation 35

36 on the Agency Website Once on the Institutional Reimbursement page, navigate to the header Hospitals/ Surgical Centers. Click on this header. Understanding ing Implementation 36

37 on the Agency Website Once on the Hospital Rates/ Surgical Centers page, scroll down and navigate to the header Hospital Outpatient Prospective Payment Reimbursement Methodology/ASC. Click on this header. Understanding ing Implementation 37

38 on the Agency Website This page contains information provided by Navigant, including the calculator, and simulation examples. The Agency will update this page periodically as the process continues. To access this page directly, follow this link: nce/finance/institutional/hoppps.shtml. Understanding ing Implementation 38

39 on the Agency Website Calculator Understanding ing Implementation 39

40 on the Florida Medicaid Web Portal The Florida Medicaid Public Web Portal has a new page dedicated to implementation. Access the page by visiting: Hover over Agency Initiatives. Understanding ing Implementation 40

41 on the Florida Medicaid Web Portal Once the cursor triggers the dropdown Agency Initiatives menu, navigate to Pricing. Click on Pricing. Understanding ing Implementation 41

42 on the Florida Medicaid Web Portal This page will be updated regularly with new information and materials for download. Understanding ing Implementation 42

43 Helpful Documents An Quick Reference Guide is available now on the public Web Portal. The image to the right is a screen capture of the document. This material contains relevant information conveniently placed in one location. A Frequently Asked Questions document is available now on the public Web Portal and a Web Based Training (WBT) will be available soon. Visit the Florida Medicaid Public Web Portal often as updates are made on a regular basis. Understanding ing Implementation 43

44 Provider Alerts Provider Alerts are sent via to inform providers of Florida Medicaid updates and changes to billing rules. Providers are strongly encouraged to subscribe to receive alerts on the Agency s Florida Medicaid Healthcare Alerts page ( rts/alerts.shtml), and monitor their for important related updates. Archived alerts can also be accessed via the Florida Medicaid Public Web Portal at Hover over Provider Services on the home page, then Support, and select Alerts. Understanding ing Implementation 44

45 Q&A Understanding ing Implementation

46 Q&A for Hospitals Will access to the er be available in the same manner as it was for DRG? Providers can work with 3M on acquiring the new ing Software. Will providers be able to verify assignment for future claims containing significant/ancillary procedures? Impacted providers will need to purchase 3M software and perform grouping on their own if they wish to determine exactly which procedures were identified as significant or ancillary by the grouping software once pricing is implemented. What should we do if the pricing on my remittance advice is different from the Calculator price? Providers should defer to the pricing provided on the remittance advice, as the payment information calculated by Florida Medicaid Management Information System (FLMMIS) supersedes the Calculator s payment calculation. Understanding ing Implementation 46

47 Q&A for Hospitals Continued Where can providers obtain the Agency s recent fiscal comparison by provider? This information will be made available on the Agency s website. Will the health plans be required to use? No, health plans are not required to use. Providers should contact the health plan directly with additional questions regarding their reimbursement method. How will the health plans decision to use or not use s be communicated to providers? The health plans are responsible for communicating their decision directly to their providers. What version of the er will the state be implementing? Version 3.12 is being used to determine payment. Understanding ing Implementation 47

48 Q&A for Hospitals Continued Will there be a transitional grace period? There is a prospectively calculated 5% cap on gains and losses in year 1. The Pricing Session, hosted by Navigant, will provide more in depth information regarding the transitional period. Will the materially affect the coding of outpatient records? Only with the requirement to add procedure codes. Do s apply to outpatient behavioral health services? Yes, s apply to outpatient behavioral health services. How will Physical Therapy, Occupational Therapy, and Speech Therapy be reimbursed for outpatient hospital based clinics? These services will be assigned an code to determine a reimbursed amount based on billed revenue and procedure codes. Understanding ing Implementation 48

49 Q&A for Hospitals Continued Will we be reimbursed for the facility or the 510 revenue code? If so, what are the billing requirements for this code? This revenue code, 0510, will be treated like any other under pricing. A price will be determined if the service line is billed with a valid HCPCS code and an code gets assigned. And then the price will depend on the s relative weight and the discounting and bundling, if any, that occur. Will the Medicaid Managed Care organizations be required to convert to as well? Health plans are not required to change outpatient reimbursement methods. Some health plans may choose to follow the fee-for-service model and transition to the payment method. Providers are encouraged to contact the health plans for additional questions regarding their transition. What data components are used by the grouper to arrive at the group code? Detail line procedure codes and modifier, diagnosis codes (for medical visits), patient age and patient gender are used to arrive at the group code. Understanding ing Implementation 49

50 Q&A for Hospitals Continued If a patient outpatient services span more than one date of service, do we continue to bill each date of service separately or should the services be billed on a single claim? Providers will continue to bill each date of service separately, as they currently do today. Presently, outpatient claims may only span from one date of service to the next if the admit type is 1 (emergency) or 5 (trauma center), and the detail dates of service fall within the span used at the header. How is the rate calculated? Do we need to put an on claim? Providers are not required to put an code on their claim. The Agency will determine initial base rates for active hospitals and ASCs. The rates will be established for the fiscal year 2017/2018 implementation. Base rates can be found on the Agency s website ( under Institutional Rates. Understanding ing Implementation 50

51 Q&A for Hospitals Continued Physical therapy, Occupational therapy and Speech therapy are currently billed separately with their own authorization number. How will this change? Will we be able to bill all 3 services on one claim and will there be space for all 3 authorizations? Hospitals billing for an outpatient procedure(s) that require a PA will need to include a PA number on the outpatient claim submission. If there are multiple PAs, one PA number must be included on the claim, and any additional PAs will be systematically located. All services for a single outpatient visit must be billed on one claim submission. Is there a PDF version of this Webinar available for download? This presentation will be made available on the Medicaid Public Web Portal after July 1. You may also work with a Field Rep if onsite training is required. Understanding ing Implementation 51

52 We Are Here to Help! Visit the Agency and Florida Medicaid Web Portal pages for webinar dates and additional training information. Call the Provider Services Call Center at , option 7, to schedule a visit with a Field Representative. Understanding ing Implementation 52

53 Thank you Feel free to visit the Florida Medicaid Public Web Portal to stay up-to-date on all things Florida Medicaid. Understanding ing Implementation