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IHS Third Party Reimbursement Overview. IHS Legislative Authority, Title 18 and 19, Mcare/Mcaid in 1976, PI in IHCIA Special Fund/JCAHO Compliance BO development, 1992-93, IG Report in 1994 cited need for improvements IHS Business Plan, 1995
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IHS Legislative Authority, Title 18 and 19, Mcare/Mcaid in 1976, PI in IHCIA Special Fund/JCAHO Compliance BO development, 1992-93, IG Report in 1994 cited need for improvements IHS Business Plan, 1995 Optimize Reimbursements to raise health status of AI/AN people BACKGROUND ITEMS
FY1998-2001 Rates for the Lower 48 States Medicaid Medicare I/P O/P O/P • CY 1998 $1,040 $168 $138 • CY1999 1,065 172 138 • CY2000 1,157 172 139 • CY2001 1,306* 185 157 • $ Increase 149 13 18 • % Increase 13% 8% 13%
3RD PARTY REVENUE IMPACTS • National------Laws, Regulations, Policy • State-----------Laws, Regulations, Policy • SU Operational improvements ie., staffing, documentation, coding training • Leadership/Management Knowledge and Awareness Levels of issues impacting third party revenue (better decisions) • Medicare and Medicaid Negotiated Rates • Current and Future Health Care Delivery Changes/Trends ie., Aging, Eligibility
IHS Unique Characteristics • IHS charged with fulfilling Federal Government’s Health Obligation to Tribes • Treaty Rights, Legislation, Exec. Orders • Authority as Federal Provider to collect • Bottom line for IHS is Increasing Health Status versus profit motive • DHHS Secretary Special legal Authority on working with IHS ie., M & M rates • FMAP for Mcaid is 100% Federal funds • IHCIA---landmark legislation 1976-present
IHS Reimbursement Types • Medicare Part A, Hospital charges • DRGs for inpatient • Encounter rate for Hospital outpatient • Medicare Part B, Professional services • Itemize services and receive payment under the Medicare physician fee schedule, no authority for other Part B ie., ambulance, home care, DME • Medicaid & SCHIP • Inpatient @ per diem rate • Outpatient @ encounter rate (incl. Physician charge) • For inpatient itemize physician services & bill @ State fee schedule • Private Insurance bill @ fee schedule • Other (workmen's comp, auto liability, Commissioned Officers)
Tribal Reimbursement Types • Tribal Options Outpatient • Federally Qualified Health Center (FQHC) for Mcare and Mcare • Memorandum of Agreement (MOA) & use IHS outpatient rates (Mcaid only) • Physician number @ Mcare fee schedule • Tribal Options Inpatient • Use IHS Rates for M Caid & Mcare DRGs • Just like private provider (tribal facility) • For Private Insurance same as IHS • Itemize Outpatient and Inpatient
3rd Party Revenue Impacts • Federal/State Laws, policy & regulations • SCHIP, Mcare Part B, Mcare Diabetes, Hospital Provider based clinics • M & Mmanaged care initiatives • HCFA Reimbursement policy ie., APCs, Capital payments, pharmacy • M & M rate setting • Cost reports (CR) effect rate • Currently 4th year 25 hosp, 12 areas for 2002 rates, add 11 more CR sites for 2003 Rates • Future CR required to establish rates & any adjustments for inflationary increases.
3RD Party Revenue Impacts • Management and Operational (BO, MR & Operational/Clinical Improvements) • Patient Registration/Alternate Res • Provider Documentation • Coding and Data entry • Billing electronically • Followup on Accts Rec • Information System Improvements • All payers e.g., auto liab, workmen's comp, Comm Corp, other military, MCOs
FUTURE ISSUES/IMPACTS • Medicare APCs-- Represents a big change for all involved SU staff, postponed until 1/2004) • Proposed Legislative Fixes • CHS payment at Medicare like rates for IP-save $$$ • 100% FFP for Admin---eliminate enrollment barriers • Mcare Inpt Phys reimb – Part B victory! • Mcare reimb for IHS Freestanding OP clinics-victory! • Expand Tribal direct M & M billing and collections Demonstration—victory! • SCHIP cost sharing exemption for Indian Children—victory! • IHCIA Title IV changes (SSA Title 18,19,21) • BO initiatives (see workplan)
FUTURE continued…………….. • Strengthen HCFA/IHS Joint Steering Committee/workgroups to address National policy/reimbursement issues • Legislative, Policy and Operations, Cost Reports/Reimb, (TAG for HCFA) • HCFA Tribal consultation/policy development (policy papers) • Third Party Compliance Plan (CP) • Other Regs ie., HIPAA, M & M changes (for example, diabetes coverage, pharmacy, Mcaid expansion) etc.
Future Continued……… • Cost Report Development and Implications for setting rates? • Medicare per capita Demo possibility • DHHS/HCFA Administration Philosophy???? • IHS/Area/SU management priorities • Assess CAH pros and cons • Cost Accting System/interface with RPMS
Current Activities on Compliance • We have simplified billing method • Ongoing training, National & Local • Documentation, coding, Accts Rec • Plan development 1.5 years ago • Currently have _____ plans in place at ______ % of hospital facilities • Initiative to train coding staff to become certified by National bodies
History of IHS Hospital Cost Reports for HCFA Review & Rate Setting Lower 48 Alaska Total • FY96 for CY98 6 1 7 • FY98 for CY00 11 3 14 • FY99 for CY01 16 4 20 Future Plans • FY00 for CY02 21 5 26 • FY01 for CY03 32 5 37 • All Hospitals (Info) 41 6 47
Why do Cost Reports • OMB and HCFA Requirements for Setting Rates • M&M Collections up 100% ($162 M in 1995 to $363 M in 2000) +124% • Maintain Collections & Future Rate Adj’s?? • Maximizing Collections Critical to Improving Health Status
Summary • Background Authorities • Unique characteristics of IHS • Reimbursement levels • Reimbursement Types • Major Impacts on Reimbursements • Future impacts/issues/plans/regulations • Questions?? Comments…… Send to Elmer Brewster, IHS HQs, OPH ebrewste@hqe.ihs.gov
