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 recommended capping payment s for physician and non hospit al services  S upport ed t hrough a recommendat ion from t he Direct or’s Workgroup and Tribal consult at ion

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.

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

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.

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.

Tribal Concerns  Want ed an opt -out provision  Inst ead of an opt -out IHS issued t his final rule as an opt -in opt 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 oft ware S yst ems t o calculat e payment rat es

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

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

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

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

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

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

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.

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

Contacts Ms. Terri S chmidt Act ing Direct or Office of Resource Access and Part nerships 301-443-2694 301-443-0718 (fax) Terri.S chmidt @ ihs.gov