FeeforService Initiative REVISIONS NOTE This information has been updated as of 6102016 Providers should review this information thoroughly as some of it has revised FeeforService Initiative ID: 701829
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Slide1
Tier 3State-fundedProviders
Fee-for-Service InitiativeSlide2
REVISIONSNOTE:
This information has been updated as of 6/10/2016. Providers should review this information thoroughly as some of it has revised.Slide3
Fee-for-Service InitiativeThe Georgia Department of Behavioral Health and Developmental Disabilities (DBHDD) is phasing in changes to the way it pays providers for delivering state-funded behavioral health services.
These changes begin July 1, 2016, and include a migration to a fee-for-service payment structure for specific DBHDD provider categories.
Some Tier Three providers deliver Medicaid-billable DBHDD specialty services (non-core) and also hold a state-funds contract to deliver specialty services. The following information only applies to Tier Three providers who currently hold a contract for state funded services.Slide4
July 1, 2016 Transition
Limited roll-out of Fee-for-Service effective July 1, 2016 to include:
Adult MH Core Benefit Package
Adult AD Core Benefit Package
Substance Abuse Intensive Outpatient Program
Psychosocial Rehabilitation - Individual and Group
Peer Support – Individual, Group, and Whole Health and Wellness
Phased transition of other Specialty Services beginning in calendar year 2017Slide5
Tier Three Provider FundingMaximum Reimbursement LimitsProviders will only be reimbursed for claimed services up to the amount of their current contract for affected services (i.e. their maximum reimbursement limit).Maximum reimbursement limits are being assigned to Tier Three state-funded specialty service providers as a statewide budgetary control mechanism. This limit provides a reasonable assurance that the state allocation for community behavioral health services is not exceeded on an annual basis.
Initial limits for FY17 will be based upon FY16 contracted values and other selected services transitioning to FFS on July 1, 2016.
Maximum reimbursement limits will be reviewed for potential adjustment to allow for possible redirects of funding at mid-year and year-end.
Reviews will be based upon actual utilization data collected.Slide6
Tier Three Provider FundingNo Minimum Reimbursement LimitsNo minimum reimbursement limits will be set for Tier Three providers.Provider revenues will be based solely on reported claims
Future FFS Transitions
Remaining services not transitioning to FFS on July 1, 2016 will transition to FFS or to fully-
costed
reimbursement beginning in calendar year 2017Slide7
Provider MRL Accumulators Claims payment will be applied to provider’s Maximum Reimbursement Limit (MRL) accumulators based on diagnosis codes on claim (MH or AD).
The
diagnosis code(s) on a claim should represent the principle condition, problem or other reason the service being billed was intended to address.
Claims paid under the fund sources SFAD (State Funds – Adult) and GACF (State Funds – Crisis) are included. Services falling under SFCA (State Funds – C&A), WTSO/WTSR (Women’s Treatment Outpatient & Residential), and TCMH/TCDC (Treatment Court – not required to report) are not included
.
The
accumulators
will add all claims paid until the MRL is reached
.
Once the MRL is reached, claims will become “pre-pay” and utilization is then tracked as state encounters
.Slide8
Providers with both MRL AccumulatorsMH and AD:The following section provides information specific to the implementation of Maximum Reimbursement Limit Accumulators for providers who will have an accumulator set up for both Mental Health and Addictive Disease services.
Provider MRL Accumulators Slide9
Providers with both MRL AccumulatorsMH and ADHow claims are applied:A mental health or addictive disease diagnosis code is required in Diagnosis Code 1 position on each claim.
Claims with two diagnosis codes will be split and 50% applied to each
MRL when applicable (providers with both MH and AD funding accumulators). If one accumulator has been reached then only 50% of the claim will be paid.
Once the MRL has been reached, claims will
be
processed in pre-pay
status and no payment will occur. The claim processes similar to state encounters
and is tracked for utilization purposes.
The scenarios on the next slides depict claims paying against MRL’s for MH and AD. Slide10
Providers with both MRL AccumulatorsMH and AD
Scenario
Claim #
Claim Amount
MH
MRL Cap
Amt
Applied to MRL
MH Balance
AD
MRL
Cap
Amt
Applied to MRL
AD Balance
1a
$150
$100,000
$150
$99,850$50,000-$50,0001b$125-$99,850$125$49,875
Remaining balances carried forward to next slide.Slide11
Scenario Claim #
Claim Amount
MH
MRL Cap
Amt
Applied to MRL
MH Balance
AD
MRL
Cap
Amt
Applied to MRL
AD Balance
2a
$84
$100,000
$84
$99,766
$50,000
-$49,8752b$54-$99,766$54$49,821Remaining balances carried forward to next slide.
Providers with both MRL Accumulators
MH and ADSlide12
Providers with both MRL AccumulatorsMH and AD
Scenario Claim #
Claim Amount
MH
MRL Cap
Amt
Applied to MRL
MH Balance
AD
MRL
Cap
Amt
Applied to MRL
AD Balance
3a
$90
$100,000
$45
$99,721
$50,000$45$49,7763b$156$78$99,643$78$49,698
Remaining balances carried forward to next slide.Slide13
Providers with both MRL AccumulatorsMH and AD
Scenario Claim #
Claim Amount
MH
MRL Cap
Amt
Applied to MRL
MH Balance
AD
MRL
Cap
Amt
Applied to MRL
AD Balance
4a
$66
$100,000
$66
$99,577
$50,000-$49,6984b$112-$99,577$112$49,586
Remaining balances carried forward to next slide.Slide14
Providers with both MRL AccumulatorsMH and AD
Scenario Claim #
Claim Amount
MH
MRL Cap
Amt
Applied to MRL
MH Balance
AD
MRL
Cap
Amt
Applied to MRL
AD Balance
5a
$70
$100,000
$0
$0
$50,000$35$49,5865b$32$16$99,850$0$0See next slide for total accumulation.Slide15
Applying Claims to AccumulatorsOnce an accumulator reaches $0, subsequent claims become pre-pay and no longer paid fee for service.
Scenario
Claim Amount
MH
MRL Cap
Amt
Applied to MRL
MH Balance
AD
MRL
Cap
Amt
Applied to MRL
AD Balance
1a
$150
$100,000
$150
$99,850
$50,000-$50,0001b$125-$99,850$125$49,8752a
$84
$84
$99,766
-
$49,875
2b
$54
-
$99,766
$54
$49,821
3a
$90
$45
$99,721
$45
$49,776
3b
$156
$78$99,643$78$49,6984a$66$66$99,577-$49,6984b$112-$99,577$112$49,586…..…..…..5a$70$0$0$35$49,586…..…..…..5b$32$32$99,542$0$0
Note: The rows below the dashed line assume that the MRL has been reached.Slide16
Providers with one MRL AccumulatorMH or AD:
The following section provides information specific to the implementation of Maximum Reimbursement Limit Accumulators for providers who will have a single accumulator set up for either Mental Health or Addictive Disease services.
Provider MRL Accumulators Slide17
Providers with one MRL AccumulatorMH or ADHow claims are applied:A mental health or addictive disease diagnosis code is required in Diagnosis Code 1 position on each claim.
Claims with two diagnosis codes will be
applied
to
the MRL accumulator regardless of the diagnosis on the claim.
For example, if a provider has AD funding only, one accumulator is set up. If a claim is to be paid the total amount of the claim is applied to the AD accumulator.
Once the MRL has been reached, claims will
be
processed in pre-pay
status and no payment will occur. The claim processes similar to state encounters
and is tracked for utilization purposes.
The scenarios on the next slides depict claims paying against a single MRL accumulator. Slide18
Providers with one MRL AccumulatorMH or AD
Scenario
Claim #
Claim Amount
MRL Cap
Amount
Applied to MRL
MRL Balance
1a
$150
$100,000
$150
$99,850
1b
$125
$125
$99,725
Remaining balance carried forward to next slide.Slide19
Remaining balance carried forward to next slide.Providers with one MRL AccumulatorMH or AD
Scenario
Claim #
Claim Amount
MRL Cap
Amount
Applied to MRL
MRL Balance
1a
$84
$100,000
$84
$99,641
1b
$54
$54
$99,587Slide20
Providers with one MRL AccumulatorMH or ADRemaining balances carried forward to next slide.
Scenario
Claim #
Claim Amount
MRL Cap
Amount
Applied to MRL
MRL Balance
1a
$90
$100,000
$90
$99,497
1b
$156
$156
$99,341Slide21
Providers with one MRL AccumulatorMH or ADRemaining balances carried forward to next slide.
Scenario
Claim #
Claim Amount
MRL Cap
Amount
Applied to MRL
MRL Balance
1a
$66
$100,000
$66
$99,275
1b
$112
$112
$99,163Slide22
Providers with one MRL AccumulatorMH or ADSee next slide for total accumulation.
Scenario
Claim #
Claim Amount
MRL Cap
Amount
Applied to MRL
MRL Balance
1a
$70
$100,000
$0
$0
1b
$32
$0
$0Slide23
Applying Claims to AccumulatorsOnce the accumulator reaches $0, subsequent claims become pre-pay and no longer paid fee for service.
Scenario
Claim #
Claim Amount
MRL Cap
Amount
Applied to MRL
MRL Balance
1a
$150
$100,000
$150
$99,850
1b
$125
$125
$99,725
2a
$84
$84
$99,6412b$54$54$99,5873a$90$90$99,497
3b
$156
$156
$99,341
4a
$66
$66
$99,275
4b
$112
$112
$99,163
….
….
….
5a
$70
$0
$0
5b$32$0$0Note: The rows below the dashed line assume that the MRL has been reached.Slide24
Questions?Please submit any questions to
FFS.questions@dbhdd.ga.gov