A Providers Perspective Overview Healthcare Environment Ambulance Payment Reform Shortterm Funding Solutions for MIH Q amp A The Journal of the American Medical Association JAMA Background ID: 619733
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Slide1
Health Care Reimbursement
A Provider’s PerspectiveSlide2Slide3
Overview
Healthcare Environment
Ambulance Payment Reform
Short-term Funding Solutions for MIH
Q & ASlide4
The Journal of the American Medical Association (JAMA)Slide5
Background
2007 GAO Report
2012 GAO Report
2013 MedPAC Study
2015 OIG Report
CMMI Grant AwardsSlide6
Differences with 2012 Report Raise Questions for Policymakers
GAO 2007
GAO 2012
Medicare reimburses ambulance service providers less than the cost of providing services
With critically important caveats GAO found:
The average margin was 6% below
In Super Rural areas it was 17% below
AAA survey findings were similar
Medicare still reimburses ambulance service providers less than the cost of providing services
The median Medicare margin with add-on payments: -2% to +9%
The median Medicare margin without add-on payments:
-8% to +5%
An increase of 59 percent over this period in BLS nonemergency transportsSlide7
MedPAC Questions New Money; Expansion of Nonemergency Slide8
Dialysis Transports:
Primary Area of Concern
MedPAC found a rapid increase in non-emergency dialysis-related transports and inappropriate billing
Source: MedPAC Presentation (Oct 2013)Slide9
September OIG Report: Questionable Claims
Concern: increase in utilization
2.7% claims examined were questionable (2012)
Questionable does not mean fraudulent
52% were in Philadelphia, LA, NY, and Houston
21% of suppliers had one or more claims with a questionable billing practice; 81% only oneSlide10
The OIG Recommendations
Determine whether a
temporary moratorium
on ambulance supplier enrollment in additional geographic areas is warranted
Require ambulance suppliers to
include the National Provider Identifier
of the certifying physician on transport claims that require certification
Implement new claims processing edits or improve existing edits to prevent inappropriate payments for ambulance transports
Increase its monitoring
of ambulance billing
Determine the appropriateness of claims billed by ambulance suppliers
identified in the report
and take appropriate action Slide11
Results Not Bad, but the Media…Slide12
Moving Forward?Slide13
What Does This Mean?
Ambulance Payment Reform:
Cost Survey
Supplier to Provider
Tie payment to cost then quality
$ follows appropriate mode of treatmentSlide14
The Evolution of Ambulance PaymentsSlide15
Key AAA Reform PrinciplesSlide16
Industry PartnershipSlide17
Payment Reform Timeline RecapSlide18Slide19
Supplier to Provider: Why?Slide20
Ambulance Services Evolved
Institute of Medicine:
Emergency Medical Services at a Crossroads
(2007)
“When illness or injury strikes, Americans count on the emergency care system to respond with timely and high-quality care.”
Provide medical services
State-of-the art care technologySlide21
Nonemergency: Medical Services Slide22
Recognizing
Ambulances as ProvidersSlide23
What It Means To Be A Provider
A survey or participate in an accreditation process
Sign a participation agreement with CMS
Submit claims electronically, unless small provider
Provide cost data to CMS
Some submit quality dataSlide24
Help Combat Fraud: ConditionsSlide25
Provider Status NecessarySlide26Slide27
Recap: Strategic ApproachSlide28
Downward
pressure
on payment rates
Productivity adjustment
Fractional mileage
Sequestration
Payment cuts to address fraud concernsSlide29
Congress Mandated a Study on Collecting Cost Data
ATRA mandated two cost studies
for ambulance services
Requirement to “consult with industry on the design of such cost collection efforts”Slide30
The AAA Developed a Workable Model for Cost Collection
Next Step
Hybrid model is feasible
NPI characteristics ready
Identify need to standardize and time
Describe survey (share if possible)
Indicate where unique nature of services required unique solutions
Indicate what worked wellSlide31
ATRA Report Support What We Know
Annual cost report is not viable option
Cannot obtain accurate cost data from hospital cost reports alone
Any data tool must take into account the variety of different ambulance services
It would be inappropriate to ignore the cost of smaller, rural, and super-rural services
Cost collection and reporting methods need to be standardizedSlide32
What is the Cost Survey?
Other Medicare Providers
AAA Cost Survey Approach
Annual Cost Report
Collect total revenue
Collect total costs
General level of standardization
Use to evaluate rates
MedPAC
The Congress
CMS
Statistical Sample
Collect total revenue
Collect total costs
Includes cost of readiness
High level of standardization
Use to evaluate rates
The Congress
CMSSlide33
The Purposeful SurveySlide34
The Cost Survey ProcessSlide35
NEXT STEPSSlide36
Snapshot of Today
Ambulance Medicare Payment SystemSlide37
Core Components of Other Medicare Payment SystemsSlide38
Payment ReformSlide39
Payment Reform Future Slide40
Short-Term Funding
Solutions for Mobile Integrated Health ProgramsSlide41
State Legislative ChangesSlide42
Private Payer Organizations
Medicare HMO
FFS may not be an option if supplier
Capitated model (PM/PM)
Commercial Payers
FFS
FFS + shared savings model
Capitated model (PM/PM)Slide43
Medicaid
1115 Waiver Program (Demonstration)
State Plan Amendment
Nevada SPA approved 7/1/2016
Certified Public Expenditures (CPE)
Intergovernmental Transfer (IGT)
Provider Assessments Slide44
Fee-for-Service (FFS) Model
Factors to consider:
Cost of providing service, to include readiness
Costly ancillary supplies (itemize)
# of enrollees in the program
HCPCS/CPT codes
Billing set upSlide45
FFS Model + Shared Savings
Factors to consider:
Same as FFS model but w/o built-in profit margin
Set S.M.A.R.T. goals with payer
Negotiate sliding scale SS model based upon program savings
i.e. COPD program achieves 20% ER avoidance = 20% SS payout
i.e. COPD program achieves 40% ER avoidance = 30% SS payout
i.e. COPD program achieves 50%+ ER avoidance = 40% SS payoutSlide46
Capitated Model (PM/PM)
1-25 Patients
Revenue
Visits during Year (M-F) - Based on 25
Visits per day - (25*.22 = 5.5)
Expenses
Unit expense:
Paramedic Salary - (1.4) FTE
Call Taker/Biller Salary
Benefits @ 30%
Fleet expense @ $9 /hr.
Medical supplies @ $8/patient
-
Total Incremental Expense
-
AASI Margin
-
Total Incremental Cost
$ -
Risk Adjustment
$ -
Total Cost to Customer
$ -
Total Monthly Cost
$ -
Total Per Member Per Month
$ -
Comparison )
$ -
Margin -
Risk Adjust.Slide47
Shared Savings Model
Full Risk to MIH Provider
Payout only occurs if S.M.A.R.T. objectives obtained
BIG risk, BIG reward if objectives reachedSlide48
Wrap Up
Short-term (End of Year)
Cost Survey
Supplier to Provider
2017 and beyond
Industry alignment imperative
Solution-oriented reformsSlide49
The easiest thing is to REACT. The second easiest thing is to RESPOND. But the hardest thing is to INITIATE.
-Seth GodinSlide50Slide51
Contact
Asbel Montes
Vice President, Revenue Cycle & Government Relations
Asbel.montes@acadian.com
337.291.4086