Revenue Cycle Trends and Updates LTC/Post Acute Care Case Management of Reimbursement
Government sponsored program days numberedPayment TransformationDelivery Model Redesign
Accountability for QualityAbility to document improved outcomesDrive reduced LOS without elevated risks of returns to hospitalStrong customer satisfaction
High Deductible EnvironmentProvider burden for estimatesImplementation/Cost of Verification tools and online technologyAcceptance of Payments electronically
ICD -10 10/1/2015
Transition to Price Based Payment
Three key pieces of legislation
Affordable Care Act (Medicaid Expansion)Health Benefit Exchange Financial Alignment Demonstration
Cost Based vs Price Based OperationCOST BASED
Government Sponsored, Per Diem
PRICE BASED
RUGs III based Reimbursement 11/1
Possibility of higher reimbursement
Increased importance of detailed and accurate documentation
Commonwealth Coordinated Care is a program the coordinates care for dual eligible residents in the State of Virginia. The care provided is not limited to Long Term Care and includes acute, behavioral and primary services.
CCC is a State and Federal program. CMS and DMAS have chosen three MMPs (Medicare –Medicaid plans) to provide services in the five designated service regions. Anthem Healthkeepers, Humana and Virginia premier.
CCC EligibleDual Eligible
Age 21 or older
Non Hospice
Non comprehensive/Group plan/Tricare
Non QMB Only
Non PACE
Patient’s who have opted for a Medicare replacement are eligible
CCC Billing (MDS/DMAS/DSS)Custodial Assessments continue (92 days) and are transmitted to the
State (more often can help with CMI)
PPS Assessments continue on Medicare schedule and are held (ie Medicare Replacement)
Medicaid Eligibility Process remains unchanged
Redetermination process remains unchanged
Level of Care process remains unchanged
UAI process remains unchanged
Retro Medicaid, prior period will be billable to traditional Medicaid
CCC Payment, Medicaid 07/01/2014-10/31/2014
Reimbursement methods unchanged from current practice
11/01/2014
Centers will be reimbursed utilizing the Medicaid RUG III-34 grouper individual cmi risk adjustment payment
07/01/2014
Price BasedDirect rate =
Avg center case mix
Direct Cost to Ceiling not as important
No rate letters issued
11/01/2014
Price BasedDirect rate =
Resident Medicaid score
RUG III -34 grouper RUGS scores entered on
Medicaid claim
Medicaid Reimbursement Changes
12/31/2017
CCC Program ends
DMAS will enroll fee for service
populations into a MLTSS program
Potential Future Changes
CCC to MLTSS transition
Consistent with General Assembly directives in years 2011 and 2015 the Department of Medical Assistance Services will transition the majority of remaining Fee for Service (FFS) Medicaid enrollees into a coordinated and integrated managed care program
Intellectual Disability Programs will more than likely remain Fee for Service
CCC to MLTSS transition
DMAS will procure health plans to Administer the MLTSS program via a competitive procurement process (RFP)
Selected plans must have or be working towards obtaining the NCQA accreditation and approval by CMS to operate as a Dual Special Needs Plan
MLTSS will operate State-wide, plans may vary by region, there must be at least two health plans per region
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