Colorado Title XFamily Planning Program

Cost Analysis/Rate Setting Part 3: Putting it all together

PUTTING IT ALL TOGETHERIntroduction

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

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

Cost Analysis Spreadsheet

Codes vs. Volume Spreadsheet

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

Family Planning CPT Codes

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

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%

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

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

Sliding Fee Scale – 5 Code Model

NEGOTIATING CONTRACTS WITH COMMERCIAL PAYERS

How to

Negotiating Contracts with Commercial Payers

Negotiating Contracts with Commercial Payers

Do you need the health plan to direct volume to you?

Can the health plan direct volume to you?

Questions to Ask

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

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

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

Definitions: Clean Claim

Contracting Payer

Covered Services

Notification of Policy Changes

Key Components of the Contract

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

Office hours/after hours care

Timely filing

Claim submission

Non-discrimination

Medical records

Policy manual

Provider directory

Collect Co Pay

Provider Obligations

Multi-year term

Termination without cause

Term and Termination

Reciprocity

Amendment process

Indemnification

Legal proceedings

General Provisions

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

Review contracts and fee schedules at least every 2-3 years

Contracting and Credentialing are ONGOING Processes

stay active, stay engaged in this process

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

CDPHE Hub ResourcesFor all training events, meetings, and conferenceshttps://sites.google.com/site/titlexhub/trainings-and-conferences