Emergency Department Medicaid Policy and Medicaid Update Kellie - - PDF document

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Emergency Department Medicaid Policy and Medicaid Update

Kellie Cornelius, MAP, CPEHR, CPHIT AFMC Provider Outreach Specialist

Arkansas Medicaid is the only insurance carrier in Arkansas to reimburse for three different emergency department (ED) service types that may be provided to an Arkansas Medicaid beneficiary.

• Assessment
• Non-emergent treatment
• Emergent treatment

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Assessment Assessment Assessment Assessment is an evaluation of the beneficiary’s complaint or presenting condition. During an assessment, diagnostic testing may be performed to determine the beneficiary’s condition. Treatment that requires a skilled medical person to perform may not be given to the beneficiary. An assessment does does does does not not not not require a referral from the beneficiary’s primary care provider (PCP). However, in order for the assessment to be covered, the beneficiary being assessed must be enrolled with a PCP if their Medicaid aid category requires PCP assignment.

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Non Non Non Non-

• emergent

emergent emergent emergent treatment occurs after an assessment has been performed and the beneficiary is deemed non-emergent and is given the choice and elects to receive non-emergent treatment in the ED, rather than being discharged after receiving an assessment and referred to their PCP for follow up care. The only time Medicaid will reimburse for non-emergent treatment in the ED without a PCP referral without a PCP referral without a PCP referral without a PCP referral is when non- emergent treatment is rendered on the same day the beneficiary was assigned to a PCP by the ED. PCP assignment can be made during the beneficiary’s ED visit by calling the Voice Response System (VRS) and following the automated PCP assignment steps. The PCP assignment service must be billed on the same claim form as the non-emergent treatment. The hospital will receive a $5 fee for assigning the PCP the beneficiary selected.

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For those beneficiaries who have a PCP when they present to the ED, it’s their PCP’s discretion whether to give a referral for non-emergent treatment in the ED. This includes non-emergent treatment given in the ED after normal PCP office hours. *AFMC’s policy and education outreach services representatives educate PCPs not to give referrals to the ED for non-emergent treatment, especially during office hours.

Section 213.400 of the Hospital Manual Section 213.400 of the Hospital Manual Section 213.400 of the Hospital Manual Section 213.400 of the Hospital Manual 213.400 PCP Enrollment in the Hospital Outpatient Department 10 213.400 PCP Enrollment in the Hospital Outpatient Department 10 213.400 PCP Enrollment in the Hospital Outpatient Department 10 213.400 PCP Enrollment in the Hospital Outpatient Department 10-

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Medicaid covers emergency services only for recipients with no PCP.

• A. Staff at participating hospitals may facilitate recipients’ PCP selections.
• 1. A Medicaid recipient must complete a form DMS-2609, Primary Care Physician Selection and

Change Form, in order to enroll with a PCP. View

• r print form DMS-2609 at www.medicaid.state.ar.us/Download/Provider/

ProvDocs/Forms/DMS-2609.doc

• 2. Hospital personnel enter the PCP selection via the Voice Response System (VRS). View or print

VRS contact information at www.medicaid.state.ar.us/ Download/provider/ProvDocs/Links/PCPEnrolVRS.doc

• 3. The enrollment is effective immediately and its effective date is the date of entry.
• 4. The hospital staff must forward a copy of the form DMS-2609 to the PCP entered on the VRS

and give a copy to the enrollee.

• B. Arkansas Medicaid reimburses hospitals (PCP Enrollment Fee — see Section 272.400 for special

billing instructions) for the enrollment assistance.

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For adult beneficiaries (age 21 and over), non-emergent visits count toward the 12 outpatient hospital maximum per State Fiscal Year (SFY) July 1-June 30. Beneficiaries under age 21 are not subject to the 12

• utpatient hospital benefit limit.

The non-emergent PCP referral rule applies to beneficiaries

• f all ages.

The emergent visit emergent visit emergent visit emergent visit is based on the prudent layperson’s definition of “emergency medical condition:” A prudent layperson is someone with an average knowledge of health and medicine who would expect the lack of immediate treatment to cause significant deterioration of the beneficiary’s health. From the Medicaid Manual — Section 213.300 (B): The prudent layperson standard

• f the Balanced Budget Act of 1997 forbids Medicaid denial of a hospital’s claim for
• utpatient assessment based on the discharge diagnosis. The law establishes that a

person who believes he or she should seek medical attention at a hospital emergency department must be permitted to do so. Medicaid may not require the individual or the hospital to obtain prior approval for the visit and may not refuse coverage of the visit based on a non-emergent discharge diagnosis.

• Sudden or Recent Onset of Symptoms
• Presenting Chief Complaint

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Neither a referral nor a prior authorization is required for emergent treatment in the ED. Inpatient hospital admissions resulting from treatment in the ED do do do do not not not not require a PCP referral. Direct inpatient hospital admits by the beneficiary’s PCP do do do do require a PCP referral.

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Additional Policy References Additional Policy References Additional Policy References Additional Policy References

Arkansas Medicaid Hospital Manual - https://medicaid.mmis.arkansas.gov/Provider/Docs/hospital.aspx AFMC Provider relations – policy and education https://afmc.org/health-care-professionals/arkansas-medicaid- providers/policy-and-education/ What’s New for Arkansas Medicaid Providers https://medicaid.mmis.arkansas.gov/Provider/newprov.aspx

KC1

Slide 14 KC1

Kellie Cornelius, 9/28/2018

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Episodes of Care

New Episodes New Episodes New Episodes New Episodes

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PASSE

Provider Provider Provider Provider-

• led Arkansas Shared Savings Entity (PASSE)

led Arkansas Shared Savings Entity (PASSE) led Arkansas Shared Savings Entity (PASSE) led Arkansas Shared Savings Entity (PASSE)

• Phase I – began Oct. 2017
• Independent assessments
• PASSE assignment
• Care coordination
• Phase II – Jan. 2019
• Global payment from DMS
• Full risk

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PASSE Contact Information PASSE Contact Information PASSE Contact Information PASSE Contact Information

• Arkansas Total Care – www.arkansastoalcare.com

John Ryan – jryan@centene.com

• Empower Healthcare Solutions –

www.getempowerhealth.com Nicole May – nicole.may@beaconhealthoptions.com

• Forevercare – www.forevercare.com

Mike McCabe – MMcCabe@ForeverHealthPlan.com

• Summit Community Care – www.forevercare.com

Jason Miller – jason.miller@SummitCommunityCare.com

Questions? Questions? Questions? Questions?