SLIDE 1
History
GAO -13-272 Capping Payment Rat es for Nonhospit al S
ervices could S ave Millions of Dollars for Cont ract Healt h S ervices
GAO recommended capping payment s for physician and non
hospit al services
S
Purchased/Referred Care Rates Office of Resource Access and - - PowerPoint PPT Presentation
Purchased/Referred Care Rates Office of Resource Access and - - PowerPoint PPT Presentation
Purchased/Referred Care Rates Office of Resource Access and Partnerships May 17, 2016 History GAO -13-272 Capping Payment Rat es for Nonhospit al S ervices could S ave Millions of Dollars for Cont ract Healt h S ervices GAO
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SLIDE 3
Overview
The new PRC regulat ion gives t he I/ T/ U t he abilit y t o cap
payment rat es at a “ Medicare-like rat e” t o physicians and ot her non-hospit al providers and suppliers t hrough t he PRC program. These rat es will be known as t he PRC rat es.
The Direct or’s Workgroup on Improving PRC support t he rule.
SLIDE 4
Overview
NPRM published December 5, 2014
- Ext ended t o February 4, 2015 t o allow for a 60 day comment
period
- IHS
received 54 t imely comment s
PRC Final Rule published in FR on March 21, 2016
- IHS
addressed all comment s in t he Preamble of t he Final Rule
SLIDE 5
Overview
Effect ive dat e is May 20, 2016 Tribes have t he opt ion t o opt -in t o t he rule and implement
immediat ely or when t hey are able t o fully implement t he rule, provided t hat t hey have agreed in t heir cont ract / compact t o adopt .
A PRC program operat ed by t he IHS
should implement t he rule as soon as possible, but must implement t he rat es no lat er t han March 21, 2017.
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Tribal Concerns
The maj orit y of Tribes support t his rule There are some concerns as follows:
- Providers will refuse t o see our pat ient s
- Implement ing PRC rat es will likely increase t he volume of
services being sought which will result in providers achieving more volume t o offset t he decrease in rat es.
SLIDE 7
Tribal Concerns
Want ed an opt -out provision
- Inst ead of an opt -out IHS
issued t his final rule as an opt -in
- pt ion for Tribes
The final rule is opt ional for t he Tribal PRC programs
- In accordance wit h t ribal sovereignt y and self-
det erminat ion, Tribes have t he right t o opt -in, but cannot be required t o do so.
Out reach & Educat ion S
- ft ware S
yst ems t o calculat e payment rat es
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Implementation Steps
IHS
issued a Press Release
All Tribes Call Dear Tribal Leader Let t er The FI provided HQs PRC st aff wit h a draft t raining module
SLIDE 9
Implementation Steps to Date
IHS
is scheduling webinars
- PRC S
t aff Educat ion
- Federal & Tribal
In person t raining sessions
- OIT/ ORAP Part nership Conference
Online t raining module Not ificat ion t o Medical providers
- Dear Provider Let t er
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What do the PRC Rates Regulations do?
Allows t he I/ T/ U t o negot iat e wit h and pay healt h care
providers or suppliers who deliver healt h care professional & non-hospit al-based services t hrough PRC
- Using a “ Medicare-like rat e.”
PRC programs oft en paid billed charges which is higher t han
privat e insurers, and ot her federal programs, such as:
- Medicare
- TRICARE
- V
A
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What do the PRC Rates Regulations do?
PRC payment is capped at the MLR, unless it is the most favored customer (MFC) rate; however, the price can exceed the MFC if fair and reasonable and in the best interest of the I/ T/ U
I/ T/ U’s can negotiate higher rates of payment with providers
- Must meet a reasonable pricing arrangement
- MFC rate is a platform for negotiation
- MFC is another rate that providers charge to other entities like insurance
providers
- It is incumbent on the provider or supplier to provide this rate to PRC
staff
It is the responsibility of the I/ T/ Us to calculate/ estimate payment rates
The actual payment amount is provider specific
SLIDE 12
What Services are Covered?
Out pat ient care Physicians Laborat ory Dialysis Radiology Pharmacy Transport at ion services (Ambulance) *This is not a complet e list of services
SLIDE 13
How to Take Advantage of PRC Rates
The opt-in opt ion only applies t o Tribal PRC programs
- Tribes can include language in t heir funding agreement
which has t he suggest ed st at ement below or somet hing similar
- Tribal Healt h Program agrees t o be bound by 42 CFR
part 136, subpart I in t he administ rat ion and provision of PRC services carried out under t his Agreement
SLIDE 14
Savings
The savings realized will allow t he I/ T/ U t o purchase more
healt h care services
Implement ing PRC rat es will likely increase t he volume of
services being sought which will result in providers achieving more volume t o offset t he decrease in rat es.
SLIDE 15
Claims Processing Options
Use t he IHS
Fiscal Int ermediary via “ buyback”
Cont ract wit h a t hird part y administ rat or Download t he PC PRICERs from CMS
Websit e – www.cms.gov
Purchase PC PRICER commercial soft ware
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Contacts
- Ms. Terri S