Medicare FQHC PPS: Lessons Learned throughchcnetwork.org/.../06/Medicare-FQHC-PPS-Webinar_Final.pdf · 2019. 1. 6. · Medicare Cost Report Implications The “New” Medicare FQHC

Medicare FQHC PPS:

Lessons Learned through

Implementation

R E G U L AT O RY AF FA I R S

T U E S D AY, J U N E 9 , 2 0 1 5

2 P M E S T

M I K E S C H N AK E , PAR T N E R , B K D

R E B E K AH WAL L AC E PAR D E C K , D I R E C TO R , B K D

Presentation Prelude

Implementation of the Medicare FQHC PPS provides opportunity for FQHCs to potentiallyimprove Medicare reimbursement results

Does implementation achieve increased reimbursement versus the old “cost-based” system?

As good as the CMS “headline” numbers?

Implementation of Medicare FQHC PPS is not a “one and done” process

Ongoing considerations over time

Reconsideration of Medicare as a “book of business”?

Agenda

Review PPS Basics

Implementation Challenges

Medicare Cost Report Implications

Medicare Advantage Plan Considerations

Q&A

FQHC PPS Background Basics

Effective 10/1/14 – based on cost report year-end

All Health Centers will transition by 9/1/2015

Base Rate X Geographic Adjustment Factor (GAF)

Established = $158.85 x GAF

Higher Intensity = +34.16%

FQHC PPS Background Basics

Established five unique payment codes

Payment lesser of PPS rate or provider charge for traditional Medicare claims

Medicare Advantage claims are “wrapped” to PPS rate

FQHC Implementation Challenges

Establishing charge for new payment codes

• Limited direction from CMS

• Lack of policies and procedures guiding fee establishment

• Existing fee structures that are outdated, reflect low charges and/or noncompliant

• Not allowing adequate time for assessing fees, fee revisions and obtaining Board approval

FQHC Implementation Challenges

Coding

• Potential under-coding

• Incomplete capture of services rendered in

• Not rendering, documenting correctly or coding for higher intensity visits including IPPE and AWVs

FQHC Implementation Challenges

Practice Management Systems

• Vendor education needed on PPS changes

• Allowing sufficient time for system upgrades/changes

• Impacts on reporting, claims and payment processing and patient accounts

FQHC Implementation Challenges

Billing and Claims Changes

• New payment codes not recognized by Payers outside of Medicare

• Procedures prompting payment change under PPS

• Correlation of CPT codes to new payment codes

• Medicare Advantage reimbursement and claims procedures often not understood

• Increase in Medicare beneficiary copay (in many cases)

FQHC Implementation Challenges

Guidance

• Limited/changing guidance from CMS

• Ongoing changes in “qualifying visits” as defined by CMS

• Changes in GAFs

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Medicare Cost Report Implications

The “New” Medicare FQHC Cost Report

Applicable for cost reporting periods ending on or after September 30, 2015

• CMS has indicated that reasonable costs of the following services will continue to be determined and paid through the Medicare FQHC cost report (there will be a cost report settlement amount)

• Influenza and pneumococcal vaccines and their administration

• Allowable graduate medical education costs

• Medicare bad debts

Medicare Cost Report Implications

The “New” Medicare FQHC Cost Report

• CMS published a “notice” regarding the Medicare FQHC cost report revision in the Federal Register of December 19, 2014

“New” cost report = Form CMS-224-14

Notice was not well publicized to the industry

• Identified on February 11, 2015

Notice included a public comment period that ended February 17, 2015

• Comment letters by NACHC and BKD were timely filed

Medicare Cost Report Implications

The “New” Medicare FQHC Cost Report

• Proposed “new” cost report form is significantly altered from the current cost report form

Many of the proposed changes are troublesome

• Proposed “new” cost report form:

Includes a variety of new information that will be required

Combines the previous cost report and cost report questionnaire into one document

Anticipated to require approximately 20% more hours for completion based on CMS comments

Medicare Cost Report Implications

The “New” Medicare FQHC Cost Report

• Overarching area of concern:

Inconsistencies in the calculation of a FQHC’s total cost per visit

• Implementation of the Medicare PPS did not change the nature of cost finding for FQHCs

• Integrity of the Medicare PPS may be compromised

Medicare Cost Report Implications

The “New” Medicare FQHC Cost Report

• CMS has indicated that cost report information will be used to update cost estimates and to facilitate the potential development of a FQHC market basket

Beginning January 1, 2016, PPS payment rates will be increased by the percentage increase in the MEI

Beginning January 1, 2017, PPS rates will be increased by the percentage increase in a market basket of FQHC goods and services as established through regulations, or, if not available, the percentage increase in the MEI

• Accurate preparation of the cost report will continue to be important in the PPS environment

Medicare Advantage Plan Considerations

Medicare Advantage Plans in the PPS Environment

Coordinated Care plans (CCPs)

• Primarily HMOs & PPOs

• Provide care through established provider networks

Private Fee-for-Service plans (PFFS)

• May or may not have an established provider network

Medicare Advantage Plan Considerations

Medicare Advantage Plans in the PPS Environment

• For FQHCs under contract (directly or indirectly) with MA Organizations

CMS has indicated that the supplemental “wrap-around” payment will be based on the applicable PPS rate without comparison to the FQHC’s charge

• Important to successfully navigate the process of establishing appropriate “wrap-around” rate(s)

QUESTIONS

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910 E. St. Louis St.

Springfield, MO 65801-1190

Office: 417.865.8701

Fax: 417.865.0682

www.bkd.com

Michael B. Schnake,

CPA, CGFM

Partner

mschnake@bkd.com

Rebekah S. Wallace Pardeck,

CMPE, CPC, MCS-P

Director

rwallace@bkd.com

CMS Websites

FQHC PPS website:

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/Index.html

FQHC Center website:

http://www.cms.gov/Center/Provider-Type/Federally-Qualified-Health-Centers-FQHC-Center.html

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Disclaimer

The information contained in this presentation is not intended to cover all situations or all rules & policies. Reimbursement laws, regulations & policies are subject to change.

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Thank you for joining us!

• Next webinar:

–What’s New with the 340B Drug Discount

Program?

–Thursday, June 25, 2015 2:00 pm

• For more information, please contact Colleen

Meiman at cmeiman@nachc.org or Susan Sumrell

at ssumrell@nachc.org.