FL AHCA Outpatient Prospective Payment System Design...Sep 17, 2015 · Description of Dataset to...

Florida AHCA Outpatient Prospective Payment System Design

Second Public Meeting September 17, 2015

Table of Contents

Section 1 » Comparison of EAPGs and APCs

Section 2 » Description of Dataset to be Used for OPPS Modelling

Section 3 » OPPS Payment Policy Decisions

Section 4 » Questions / Public Comment

September 17, 2015 Draft and Confidential

Section 1 Comparison of EAPGs and APCs

Comparison of EAPGs and APCs

History of OPPS

September 17, 2015 Draft and Confidential © 3M 2013. All rights reserved.


General Description

Characteristic Medicare APCs EAPGs

Patient Classifications

358 APC classifications with relative weight and 408 APCs paid on fee schedule (based on publically available grouper) 15 APCs for observation; 317 APCs for drugs

564 valid EAPG classifications (version 3.10) based on 3M proprietary grouper 191 EAPGs for observation; 23 EAPGs for drugs

Services Excludes many services which must be paid under other fee schedules (ex: laboratory, pathology, physical therapy, DME)

Covers all medical outpatient services with reported HCPCS

Claim Coding Requirements Detail-level HCPCS and modifiers for procedures Header-level diagnosis codes and detail-level

HCPCS and modifiers

Observation Payment Basis

Observation APCs pay based on self-reported effort (duration of patient contact)

Observation EAPGs pay based on patient’s condition (diagnosis and procedure). Greater clinical focus



Payment Parameters


Relative Weights

Medicare APC weights or plan-specific weights that reflect average resource requirements for service

3M national weights (based on MEDPAR data) or state-specific weights that reflect average resource requirements for service; bundled costs included in procedure weight

Provider Base Rates

• Percent of Medicare APC rates or plan-specific

• Effected by percentage of Medicare rates applied to outpatient fee schedules

Plan-specific (can be “solved” to result in budget neutral rates by provider/product)



Bundling and Discounting


Ancillary Bundling Limited ancillary bundling, many paid under APCs

Bundling for low-cost ancillaries and incidentals; separate payment for more costly ancillary services

Procedure Bundling Limited procedure bundling (specific APCs)

Significant procedure bundling for clinically related lower-weighted procedures provided during same visit

Procedure Discounting Applied to lower weighted procedures provided during same visit

Applied to lower weighted clinically unrelated procedures provided during same visit



Pros and Cons

Pro/Con Medicare APCs EAPGs

Pros

• Provides classification system for most procedures

• Provider familiarity with Medicare OPPS • Medicare rate factors readily available • Recognizes resource requirements for

significant procedures

• Provides classification system for all outpatient services/settings

• Can determine provider case mix • Recognizes resource requirements for

significant procedures AND uses bundling to incentivize efficient care

• National weights available • Requires less annual rate updates

Cons

• Minimal bundling for procedures and ancillary services

• “A la carte” ancillary payments • Tied to Medicare changes • Some services paid via fee schedule – lab,

pathology, therapies (PT, OT, ST), DME, mammography, non-implantable prosthetics

• Providers may not have familiarity with EAPG grouper

• Claim pricing more difficult to understand • Requires HCPCS on all claim lines (but

provides more specificity) • Proprietary grouper software



Processing Claim for APC Grouping and Payment

September 17, 2015

UB-04 Data

OCE Pricer

OCE Edits

Assign SI

Assign APCs (886)

APC Payments

Special Logic

• Special CMS rules • Composite APCs

Fee Schedule • Clinical labs • Therapies • DME • Ambulance

• Claim level • Line level • 83 edits

Special rates

• Outlier • Pass thru • Cost • Discounts

• Weights • Rates

Draft and Confidential

© 3M 2008. All rights reserved.


Processing Claim for EAPG Grouping and Payment

September 17, 2015

UB-04 Data

EAPG Grouper Pricer

EAPG Payments

Special rates

• Outlier • Discounts • Others

• Weights • Rates

Assign EAPGs

Special Logic

• Consolidation • Packaging

• 564 EAPGs

Draft and Confidential

© 3M 2008. All rights reserved.

Description of Dataset to be Used for OPPS Modelling

Summary by Service Line


BCBS Plans with EAPGs State Medicaid Programs with EAPGs

*

* Indicates Moving Towards / Considering

*

* *

DC *

EAPGs in Other States

* Approximately 34M lives covered in these states

Section 2 Description of Dataset to be Used for OPPS Modelling


General Description

» Outpatient claims from state fiscal year 2013/2014, processed in FMMIS through July 22, 2015

» Includes paid fee-for-service and managed care encounter claims » Excludes Medicare crossover claims » Includes hospitals (provider type 01) and free-standing dialysis centers

(provider type 89) › Claims from Ambulatory Surgical Centers (provider type 06) were not available at

the time the dataset was created » Final version of claims that had been adjusted





Claim Type Claim Lines Billed Amount Baseline Payment

Managed Care 7,754,591 5,129,382,570 547,275,370 Fee-For-Service 14,132,769 8,547,639,226 994,052,959 Total 21,887,360 13,677,021,796 1,541,328,329

Summary of Dataset by Claim Type




Service Line Claim Lines Charges Baseline Payment

Laboratory 8,365,798 1,907,671,044$ 50,080,467$ Pharmacy 4,431,267 1,391,797,693$ 457,221,527$ Emergency room 3,153,994 3,060,909,910$ 324,533,634$ Diagnostic and testing 2,364,246 3,368,170,640$ 267,763,830$ Therapies 1,018,687 296,464,344$ 124,992,601$ Care Delivery 889,850 2,015,176,313$ 119,385,978$ Supplies 850,141 410,118,922$ 95,361,228$ Observation 358,352 322,461,721$ 39,226,349$ Oncology and radiology 248,281 297,729,999$ 34,933,381$ Dialysis 156,529 575,157,631$ 22,781,493$ Blood 44,320 27,532,594$ 4,722,111$ Behavioral Health 2,315 1,368,575$ 301,745$ Error 1,831 729,198$ 19,443$ Non-Payable 953 35,960$ -$ Transportation 426 1,005,036$ -$ Organ acquisition 122 509,041$ 3,044$ DME 102 10,335$ -$ Hospice 54 21,262$ 1,500$ Room and board 45 138,655$ -$ Dental 28 6,903$ -$ Nursing 13 2,294$ -$ Telemedicine 4 3,431$ -$ Home Health 2 297$ -$ Total 21,887,360 13,677,021,796$ 1,541,328,329$

Summary of Dataset by Service Line

Notes:1) Service lines assigned based on the revenue codes.


Summary by Provider Category


Provider Category Stays Estimated Cost Charges Baseline Payment

Baseline Pay / Cost

Hospital 21,440,330 1,901,855,132$ 12,887,221,170$ 1,512,895,345$ 80%Trauma 8,353,404 796,142,103$ 4,892,815,789$ 756,238,892$ 95%General Acute 8,297,535 673,280,446$ 5,147,309,283$ 447,981,942$ 67%Safety Net 7,759,107 687,964,153$ 4,093,747,609$ 653,196,464$ 95%For Profit 6,341,536 549,757,904$ 5,019,227,458$ 325,020,258$ 59%High Charity 4,509,404 407,320,121$ 3,133,083,072$ 285,814,770$ 70%Statutory Teaching 4,043,786 412,971,532$ 2,386,875,969$ 414,183,747$ 100%Public 3,561,967 282,358,956$ 1,810,338,449$ 286,848,151$ 102%Rural 1,102,073 66,082,045$ 363,336,903$ 58,515,861$ 89%Children 1,075,857 152,937,716$ 636,883,021$ 148,393,115$ 97%Rehabilitation 56,270 1,865,120$ 7,831,852$ 2,407,183$ 129%Long Term Acute Care 68 8,153$ 45,355$ 675$ 8%Dialysis 427,852 N/A 786,913,802$ 27,432,782$ N/A

Summary of Dataset by Provider Category

Notes:

3) Out-of-state hospitals are not included in the "Hospital" category.

1) Providers may be included in more than one category.2) Costs using Medicare cost-to-charge ratios are unavailable for dialysis centers.


Claim Lines with Blank Procedure Codes by Svc Ln


EAPG Service Line Claim Lines

with Error EAPG (999)

Total Claim Lines

Percent of Total Lines with EAPG 999

Billed Amount

Baseline Payment Amount

Total Baseline Payment

Percent of Total Baseline Payment

999 Supplies 737,846 850,141 87% 303,927,375 91,911,622$ 95,361,228$ 96%999 Care Delivery 346,616 889,850 39% 655,924,986 48,614,922$ 119,385,978$ 41%999 Diagnostic and testing 264,480 2,364,246 11% 357,418,782 40,387,562$ 267,763,830$ 15%999 Emergency room 257,410 3,153,994 8% 227,637,954 40,132,591$ 324,533,634$ 12%999 Therapies 214,349 1,018,687 21% 58,387,533 35,364,296$ 124,992,601$ 28%999 Pharmacy 79,811 4,431,267 2% 39,627,715 11,950,478$ 457,221,527$ 3%999 Observation 67,201 358,352 19% 74,028,061 9,728,970$ 39,226,349$ 25%999 Dialysis 63,414 156,529 41% 197,647,648 8,941,351$ 22,781,493$ 39%999 Oncology and radiology 27,207 248,281 11% 47,597,518 6,087,642$ 34,933,381$ 17%999 Blood 3,842 44,320 9% 3,822,586 606,851$ 4,722,111$ 13%999 Laboratory 1,367 8,365,798 0% 516,003 -$ 50,080,467$ 0%999 Non-Payable 701 953 74% 20,074 -$ -$ 0%999 Behavioral Health 458 2,315 20% 326,302 60,280$ 301,745$ 20%999 DME 96 102 94% 2,559 -$ -$ 0%999 Organ acquisition 83 122 68% 343,990 3,044$ 3,044$ 100%999 Hospice 51 54 94% 12,054 1,500$ 1,500$ 100%999 Room and board 38 45 84% 137,851 -$ -$ 0%999 Error 33 1,831 2% 4,722 776$ 19,443$ 4%999 Transportation 18 426 4% 102,442 -$ -$ 0%999 Nursing 10 13 77% 1,398 -$ -$ 0%999 Dental 1 28 4% 98 -$ -$ 0%999 Home Health 1 2 50% 27 -$ -$ 0%

Total 2,065,033 21,887,356 9% 1,967,487,678 293,791,886$ 1,541,328,329$ 19%

All Claims with Blank Procedure Codes and EAPG 999 (Error)

Note: No claim lines for telemedicine services had an EAPG of 999 and are not listed in this table.


Claim Lines w/ Blank Proc Codes by Prov Categ


Provider Category

Claim Lines with Blank Procedure

Code

Total Claim Lines

Total Baseline Payments for Claim

Lines with Blank Procedure Code

Total Baseline Payments for

All Claim Lines

Percent of Total Claim Lines with Blank Procedure Code

Percent of Total Baseline Payments

with Blank Procedure Codes

Hospital 2,004,974 21,440,330 286,584,157$ 1,512,895,345$ 9% 19%Trauma 818,856 8,353,404 156,577,302$ 756,238,892$ 10% 21%General Acute 764,494 8,297,535 83,947,976$ 447,981,942$ 9% 19%Safety Net 613,194 7,759,107 101,720,970$ 653,196,464$ 8% 16%For Profit 459,637 6,341,536 43,087,623$ 325,020,258$ 7% 13%High Charity 446,572 4,509,404 62,311,175$ 285,814,770$ 10% 22%Public 405,756 4,043,786 72,149,867$ 286,848,151$ 10% 25%Statutory Teaching 345,623 3,561,967 75,589,939$ 414,183,747$ 10% 18%Children 188,013 1,102,073 41,132,916$ 148,393,115$ 17% 28%Rural 98,096 1,075,857 9,261,600$ 58,515,861$ 9% 16%Rehabilitation 55,791 56,270 2,392,671$ 2,407,183$ 99% 99%Long Term Acute Care 34 68 499$ 675$ 50% 74%Dialysis 59,480 427,852 7,068,207$ 27,432,782$ 14% 26%

Blank and Invalid Claim Lines by Provider Type

Section 3 OPPS Payment Policy Decisions

Policy Decisions

Part 1

Consideration Comments Grouping algorithm • EAPGs Hospital outpatient benefit limit • Continue to apply $1,500 limit under current rules

Model dataset • SFY 2013/14 historical data • Including both fee-for-service and managed care

claims

Provider types included and excluded from new OPPS

• Included: Hospitals • Excluded: Independent Labs, Free-Standing

Dialysis Centers, Hospice Facilities • Still under consideration: Ambulatory Surgical

Centers Services included and excluded from new OPPS

• Emergency departments, therapies, drugs, imaging, observation, etc …

Hospital base rate categories • One, a few, or many • No wage index adjustment


Policy Decisions

Part 2

Consideration Comments

Policy adjustors (if any) • Assigned by category of provider or type of EAPG

Outlier payments (if any) • If yes, how calculated?

Transition period (if any) • To temporarily limit individual hospital gains or losses

Documentation and coding improvement adjustment • Similar to DRG implementation

Timing of implementation • Implementation by July 1, 2016 may be challenging for the Fiscal Agent

Billing rules • Billing outpatient claims that include multiple days of service

Handling of drug rebates • Will payment of $0 adversely affect drug rebate process


Section 4 Questions / Public Comment …

FL AHCA Outpatient Prospective Payment System Design...Sep 17, 2015 · Description of Dataset to...

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