/
Tier One Providers Fee-for-Service Initiative Tier One Providers Fee-for-Service Initiative

Tier One Providers Fee-for-Service Initiative - PowerPoint Presentation

natalia-silvester
natalia-silvester . @natalia-silvester
Follow
365 views
Uploaded On 2018-09-23

Tier One Providers Fee-for-Service Initiative - PPT Presentation

REVISIONS NOTE This information has been updated as of 6102016 Providers should review this information thoroughly as some of it has revised July 1 2016 Transition Based upon current assessed risk ID: 676378

claim mrl providers applied mrl claim applied providers balance amount 000 cap accumulators claims accumulator reimbursement services amt scenario

Share:

Link:

Embed:

Download Presentation from below link

Download Presentation The PPT/PDF document "Tier One Providers Fee-for-Service Initi..." is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.


Presentation Transcript

Slide1

Tier One Providers

Fee-for-Service InitiativeSlide2

REVISIONS

NOTE:

This information has been updated as of 6/10/2016. Providers should review this information thoroughly as some of it has revised.Slide3

July 1, 2016 Transition

Based upon current assessed risk:

Limited roll-out of Fee-For-Service effective July 1, 2016

Adult MH Core Benefit Package

Adult AD Core Benefit

Package

Substance

Abuse Intensive Outpatient

Program

Psychosocial

Rehabilitation - Individual and

Group

Peer

Support – Individual and Group and Whole Health and

Wellness

Phased transition of other Specialty Services beginning in calendar year 2017

Phased transition of remaining GIA-based services to Fully Costed Reimbursement contracts beginning in calendar year 2017

Implementation of approval-based Supplemental Support Funds requests July 1, 2017Slide4

Adult BH Core Benefits Package

BH Assessment and Service Plan Development

Psychological Testing

Diagnostic Assessment

Crisis Intervention

Psychiatric Treatment (E&M)

Nursing Services

Medication Administration

Psychosocial Rehabilitation - Individual

Addictive Diseases Support Services

Case Management

Outpatient Services – Individual and Group

Outpatient Services – Family

Community Transition Planning

Peer Support – Individual

Peer Support – Whole Health and WellnessSlide5

Tier One Provider Funding

Maximum Reimbursement Limits

Maximum reimbursement limits are being

assigned

to

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 for the

core benefit package 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 One Provider Funding

Minimum Reimbursement Limits

Tier One providers will be eligible

for one year of transitional revenue protection in the form of guaranteed minimum levels of

reimbursement.

M

inimum reimbursement limits for FY17 will be set based on

70

%

of

a provider’s FY16

funding levels for the

core benefit package and other services being transitioned

to FFS

on July

1,

2016. Actual earned

revenues will

be reviewed and

compared to

initial Minimum Reimbursement Limits at mid-year

and

year-end.

Any

shortfall

between actual earned revenues

and

Minimum Reimbursement Limits will

be addressed through an increase in supplemental support

funding at year-end or upon approved intermediate request by contractor.Slide7

Tier One Provider Funding

Supplemental Support Funding

Supplemental Support funding for

FY17

contracts will carry forward from

FY16 contracts

Adjustments will be made

based

upon

required additional

funding resulting

from minimum reimbursement

limits, if applicable

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 2017Slide8

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

.Slide9

Providers with both MRL Accumulators

MH 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 Slide10

Providers with both MRL Accumulators

MH and AD

How 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. Slide11

Providers with both MRL Accumulators

MH 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.Slide12

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

-

$49,875

2b$54-$99,766$54$49,821Remaining balances carried forward to next slide.

Providers with both MRL Accumulators

MH and ADSlide13

Providers with both MRL Accumulators

MH 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.Slide14

Providers with both MRL Accumulators

MH 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.Slide15

Providers with both MRL Accumulators

MH 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.Slide16

Applying Claims to Accumulators

Once 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.Slide17

Providers with

one MRL Accumulator

MH

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 Slide18

Providers with one MRL Accumulator

MH or AD

How 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. Slide19

Providers with one MRL Accumulator

MH 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.Slide20

Remaining balance carried forward to next slide.

Providers with one MRL Accumulator

MH or AD

Scenario

Claim #

Claim Amount

MRL Cap

Amount

Applied to MRL

MRL Balance

1a

$84

$100,000

$84

$99,641

1b

$54

$54

$99,587Slide21

Providers with one MRL Accumulator

MH or AD

Remaining 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

$99,341Slide22

Providers with one MRL Accumulator

MH or AD

Remaining 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

$99,163Slide23

Providers with one MRL Accumulator

MH or AD

See 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

$0Slide24

Applying Claims to Accumulators

Once 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

$99,641

2b$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.Slide25

Questions?

Please

submit any questions to

FFS.questions@dbhdd.ga.gov