colorado title x family planning program cost analysis/rate setting part 3: putting it all together
TRANSCRIPT
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Colorado Title XFamily Planning Program
Cost Analysis/Rate Setting Part 3: Putting it all together
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PUTTING IT ALL TOGETHERIntroduction
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Learn to use this information to develop your fee schedule and negotiate with health plans
Understand your cost of providing Title X services
Develop your fee schedule
Negotiate with health plans
Create your sliding fee scale
Objectives
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Part 1: Determine your costs
Identify costs for everything you do
Learned to categorize expenses
https://docs.google.com/file/d/0BzHYZzM1jda-RjAxcHFxRHVrcG8/edit
Part 2: Volume and value
Determined the value of everything you do
Multiple value by volume
Apply to MFS & RBRVS
https://docs.google.com/file/d/0BzHYZzM1jda-a3RtQml0ZDZBVnc/edit
Recap
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Cost Analysis Spreadsheet
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Codes vs. Volume Spreadsheet
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MFS
There is not a fee for every code
Medicare family planning codes differ from Medicaid and other payers
Changes annually
RBRVS
There is an RVU for every code – with some exceptions (supplies, for example)
Make sure payers are utilizing most recent version
Medicare Fee Schedule and Resource Based Relative Value Scale
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Family Planning CPT Codes
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Once you conduct the cost analysis and understand your costs, you can develop your fee schedule (or chargemaster)
It is your decision as to how you decide to structure or calculate the rates in your chargemaster
Set your fees based on your expectations of what you want to be paid
When negotiating with commercial health plans, the MFS should always be the bottom
Developing a Fee Schedule
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Sample Fee Schedule Analysis1 2 3 4 5 6 7 8
CPT Code Medicare Fee Schedule
Clinic ChargeMaster
% of MFS Health Plan Rate % of MFS Target Rate % of MFS
99203 $108.19 $162 150% $119 110% $130 120%
99213 $72.81 $109 150% $80 110% $88 120%
99232 $70.10 $105 150% $77 110% $84 120%
99214 $106.83 $160 150% $118 110% $128 120%
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Must contain sufficient proportional increments so that inability to pay is not a barrier to services
Must be developed using a cost analysis of all services, including clinical, laboratory services, and supplies
Charges should be reasonable, fair, and equitable for all clients
Must be designed to cover the reasonable cost of providing each service
Sliding Fee Scale
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Required for Title X Family Planning Program
All Title X Family Planning services must “slide to $0” for clients 100% FPL or below
Must include a schedule of discounts for low to moderate income clients
Must be updated annually to incorporate most recent FPL guidelines
Sliding Fee Scale
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Sliding Fee Scale – 5 Code Model
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NEGOTIATING CONTRACTS WITH COMMERCIAL PAYERS
How to
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Negotiating Contracts with Commercial Payers
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Negotiating Contracts with Commercial Payers
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Do you need the health plan to direct volume to you?
Can the health plan direct volume to you?
Questions to Ask
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Start high – payers will ask what you want
Share that the plan is reimbursing lower than other plans based on your fee schedule analysis
Prepare to wait and wait
Prepare to negotiate
If you are not satisfied with the final offer, consider discontinuing the contracting process
Tips for Negotiating Fees
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Comprehensive family planning services
Operate using evidence-based guidelines
Teen clinics (adolescent care)
Young, healthy population
Other direct services
Convenient hours of operation
Same day/next day appointments
Types of providers (i.e., women’s health)
Multi-lingual and culturally diverse
On-site dispensing of birth control and other supplies
Reduce health plan expenses by preventing unintended pregnancies
Improve performance (chlamydia screening, cervical cancer screening, BMI, smoking cessation, etc.)
Recognize Your Leveraging Power
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Start a contact log
Find the rep (usually they are responsible geographically) Get a name and contact information
Ask for a contract
Be prepared with a pitch (“elevator” talking points)
Tax ID, Roster, any d.b.a.’s
They will most likely ask that credentialing be completed prior to issuing a contract
Rates: You do not need to beg! You are exactly what they need (you just have to make sure they know it).
Obtaining Contracts – The Process
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Definitions: Clean Claim
Contracting Payer
Covered Services
Notification of Policy Changes
Key Components of the Contract
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Provide member ID cards
Provide fee schedules
Do not include “Most Favored Nation” clause
Prompt payment provision
Written consent for additional benefit plans
Electronic capabilities
Credentialing
Privacy Protection
Health Plan Obligations
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Office hours/after hours care
Timely filing
Claim submission
Non-discrimination
Medical records
Policy manual
Provider directory
Collect Co Pay
Provider Obligations
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Multi-year term
Termination without cause
Term and Termination
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Reciprocity
Amendment process
Indemnification
Legal proceedings
General Provisions
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Restricted access to fee schedules.
Fee schedule applies to non-covered services.
Lack of clarification regarding entities with access to contract and discounts.
Payer prohibits provider from establishing panel limits and practice parameters.
Any reference to “most-favored-nation.”
Nonstandard coding, billing, or claims submission requirements.
Cumbersome (or manual) referral or prior authorization process.
Timely filing less than 90 days.
Health plan able to amend the contract without your signature.
Unacceptable Provisions
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Review contracts and fee schedules at least every 2-3 years
Contracting and Credentialing are ONGOING Processes
stay active, stay engaged in this process
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Remember to submit your 2015 Cost Analysis / Cost Setting Rationale Form by February 13th, 2015
Contact us with any questions
Don’t panic
FINAL REMINDER
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CDPHE Hub ResourcesFor all training events, meetings, and conferenceshttps://sites.google.com/site/titlexhub/trainings-and-conferences