OHIO MEDICAID HOSPITAL EAPG & BIENNIUM BUDGET MONITORING
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1 November 9, 2017 OHIO MEDICAID HOSPITAL EAPG & BIENNIUM BUDGET MONITORING Jackie Nussbaum, MHA, CPC, FHFMA Director Jen Goins, MHA, RHIA Managing Consultant
2 AGENDA & OBJECTIVES Summary of OHA & BKD Monitoring Project Why Monitoring is Important Monitoring Packages: Base vs. Optional Reporting Timeline Current Project Status Who to Contact 2
3 SUMMARY OF OHA & BKD MONITORING PROJECT OHA & BKD have partnered to offer monitoring for: Enhanced Ambulatory Patient Groups (EAPG) Implementation Biennium Budget Will use 837 (claim) & 835 (remit) files Two-year monitoring time frame July 1, 2017 July 31,
4 SUMMARY OF OHA & BKD MONITORING PROJECT EAPG Monitoring Outpatient payment methodology transition from fee-for-service to EAPGs Claims and remits for Traditional Medicaid & Managed Care Plans Utilize 3M EAPG Core Grouping Software Biennium Budget Monitoring Proposed $1.5 Billion cut to hospitals during budget Inpatient and Outpatient Claims Claims and remits for Traditional Medicaid & Managed Care Plans 4
5 WHY MONITORING IS IMPORTANT EAPG Monitoring Outpatient reimbursement methodology shift from fee-forservice to a prospective payment methodology Caveats to the EAPG methodology during the interim period Opportunities and potential pitfalls for reimbursement Risk corridors Stop loss/stop gain risk corridor of 0-5 percent 5
6 WHY MONITORING IS IMPORTANT Biennium Budget Monitoring Proposed $1.5 Billion in cuts to hospitals from Cuts on both inpatient and outpatient reimbursement Timely Medicaid budget spend reporting to OHA and the Ohio Department of Medicaid (ODM) Potential to delay and/or prevent cuts through monitoring 6
7 MONITORING PACKAGES: BASE VS. OPTIONAL Base Package Contract directly with OHA Includes the following: EAPG reimbursement and risk corridor monitoring Budget monitoring (Inpatient and Outpatient claims) Eight quarters of reporting over two-year time frame Optional Package Contract directly with BKD Includes the following: EAPG reimbursement analysis for high cost drugs & supplies, lesser of language, flat rate reimbursed services, observation, etc. Payer analysis for your hospital compared to your peer group Eight quarters of reporting over two-year time frame 7
8 MONITORING PACKAGES: BASE VS. OPTIONAL Base Package Process claims through 3M EAPG software Identify differences between calculated EAPG and remit EAPG Analyze EAPG reimbursement against fee-for-service model Summarize overall gain/loss per EAPG per NPI Risk corridor analysis by NPI and peer group based on ODM model 8
9 MONITORING PACKAGES: BASE VS. OPTIONAL Optional Package Review reimbursement by EAPG and EAPG Category by payer Review high cost drugs and supplies billed with modifier UB Calculate percent of OP Invoice claims with a medical visit EAPG Assess use of modifiers RT/LT vs. modifier 50 Review services with lesser of language; lab, radiology, pharmaceuticals and DME 9
10 MONITORING PACKAGES: BASE VS. OPTIONAL Optional Package Review for dental flat rate reimbursement applied correctly Review observation EAPGs to determine hours billed vs. reimbursed Review Behavioral Health & Substance Use Disorder services billed with modifier HE 10
11 MONITORING PACKAGES: BASE VS. OPTIONAL Optional Package Calculate clean claim rate Calculate by payer and compare to peer groups the following performance indicators: Average total days to payment Top five denials Outstanding charge dollar and claim volume > 90 days Outstanding charge dollar and claim volume > 180 days 11
12 OPTIONAL PACKAGE REPORT SAMPLE 12
13 REPORTING TIMELINE Project time frame July 1, 2017 July 31, 2019 Eight quarters of reporting Base Package Monitoring and Biennium Budget Monitoring different quarterly schedules Biennium Budget Monitoring: July 1, 2017 start EAPG Monitoring: August 1, 2017 start 13
14 REPORTING TIMELINE BASE & OPTIONAL PACKAGE Quarter Claims Data Summary Package Delivery Q1 August 17, September 17, October 17 January 5, 2018* Q2 November 17, December 17, January 18 February 28, 2018 Q3 February 18, March 18, April 18 May 31, 2018 Q4 May 18, June 18, July 18 August 31, 2018 Q5 August 18, September 18, October 18 November 30, 2019 Q6 November 18, December 18, January 19 February 28, 2019 Q7 February 19, March 19, April 19 May 31, 2019 Q8 May 19, June 19, July 19 August 31, 2019 *First quarter summary package delivery date subject to change due to enrollment of hospitals and availability of claims data 14
15 REPORTING TIMELINE BUDGET MONITORING PACKAGE Quarter Claim Payment Period Summary Package Delivery Q1 July 17, August 17, September 17 November 30, 2018* Q2 October 17, November 17, December 17 January 31, 2018 Q3 January 18, February 18, March 18 April 30, 2018 Q4 April 18, May 18, June 18 July 31, 2018 Q5 July 18, August 18, September 18 October 31, 2019 Q6 October 18, November 18, December 18 January 31, 2019 Q7 January 19, February 19, March 19 April 30, 2019 Q8 April 19, May 19, June 19 July 31, 2019 *First quarter summary package delivery date subject to change due to enrollment of hospitals and availability of claims data 15
16 CURRENT PROJECT STATUS BKD secured contracts with OHA, 3M and clearinghouse vendor Installed 3M grouper OHA issuing contracts to interested hospitals (base package) BKD issuing engagement letters to interested hospitals (optional package) 16
17 CURRENT PROJECT STATUS Key Issues Clearinghouse Updates Quadax committed to getting UB & remit files to BKD Availity in process of developing files to pass to BKD Change Healthcare preliminary discussions; hospital may be responsible for passing claims to BKD nthrive preliminary discussions Other please notify OHA and BKD Summary Package Delivery dates subject to getting contracts signed and claims data 17
18 WHO TO CONTACT Base Package: EAPG Risk Corridor & Biennium Budget Monitoring Contact: Shawn Stack at OHA Optional Package: EAPG Reimbursement & Payer Analysis Contact: Jackie Nussbaum at BKD
19 QUESTIONS?
20 THANK YOU! FOR MORE INFORMATION Jackie Nussbaum Jen Goins
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This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at http://ambetter.coordinatedcarehealth.com/ or by calling