ORAP UPDATE Pharmacy Benefit Managers, Collections, PRC Rates and GAO

Slides:

Advertisements

Similar presentations

©2010 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care. Provided.

Advertisements

505 North 20 th Street Birmingham, Alabama Telephone: csattorneys.com PROBLEM SOLVERS CONTROLLING LITIGATION COSTS.

FI Support for Medicare- Like Rates. Topics for FI discussion Overview of system changes Discontinuation of pre-pricing Critical Access reimbursement.

Module 3: TRICARE Options. 2 Module Objectives After this module, you should be able to: Describe some of the key features of the TRICARE Standard, Extra,

What is Audit Resolution? The action that will be taken to resolve Findings and Management Decisions.

Business Billing and Collection of eVA Fees Basics for Buyers Presented By: Becky Barnett, eVA Business Manager Kelly Flexon, Deputy eVA Business Manager.

IHS Budget Formulation Indian Health Service 2013 Virtual Tribal Consultation Summit November 5, 2013.

ACA: NATIVE AMERICAN PERSPECTIVE SEPTEMBER 22, 2014.

Overview Activities and Funds Available to Tribes under ISDEAA Concepts and practices with emphasis on TRIBAL SHARES, especially for Headquarters.

Overview of the Tribal Self-Governance Program in the Indian Health Service Presented by: Indian Health Service Office of Tribal Self-Governance (OTSG)

Claims Recovery Service. Prerequisites Treat patients with commercial health insurance and/or out-of-network Possess/have access to claim records: + 835s.

1 HOBBS STRAUS DEAN & WALKER, LLP WASHINGTON, DC | PORTLAND, OR | OKLAHOMA CITY, OK | SACRAMENTO, CA The Indian Addendum Ensuring Meaningful ITU Provider.

Veterans Access, Choice and Accountability Act of 2014 (VACAA) The Choice Program.

1 Legislative & Policy Update NW Portland Area Indian Health Board Quarterly Board Meeting Great Wolf Lodge – Chehalis Tribe January 27, 2015.

From Registration to Accounts Receivable – The Whole Can of Worms 2007 UBO/UBU Conference 1 Briefing:The JAG’s Role in the Third Party Collections & Policy.

Affordable Care Act and Purchased/ Referred Care aka Contract Health Services Terri Schmidt R.N. Director, Division of Contract Care Office of Resource.

Medicare Like Rates Kris Locke American Indian Health Commission September 14, 2007.

Wetlands Reserve Program Case Study An Overview of the External Audit Process Helping People Help The Land.

June 24, 2014 Karol Dixon HCA Tribal Affairs Office Medicaid Update.

1 Legislative & Policy Update NW Portland Area Indian Health Board Quarterly Board Meeting Embassy Suites, Portland OR January 22, 2014.

Utah’s Primary Care Network A health insurance access initiative Gene Davis Democratic Whip Utah State Senate.

The Medicare Hospice Benefit and Medicare Part D April 18, 2014 Janis Bivins, RN Marilyn Tatro, RN John Gochnour, Esq.

FY 2005 Indigent Care Trust Fund Disproportionate Share Hospital Program Presented to House Appropriations Health Subcommittee June 23, 2005.

LESSONS LEARNED FROM MEDI-CAL MANAGED CARE EXPERIENCE “WHAT YOU DON’T KNOW COULD HELP YOU” Mary Szecsey – Executive Director

Dean M Seyler - Area Director April 16, 2013 Quarterly Board Meeting Swinomish Casino and Lodge.

Ohio’s Percentage Income Payment Plan (PIPP) Dave Rinebolt, Executive Director and Counsel Ohio Partners for Affordable Energy PO Box 1793, Findlay, OH.

Restricted Account Status Reports November 29, 2001.

“Reaching across Arizona to provide comprehensive quality health care for those in need” Our first care is your health care Arizona Health Care Cost Containment.

NIHB 2015 Annual Consumer Conference Native Health 2015: Policy, Advocacy and the Business of Medicine Wednesday, September 23, 2015 Kim Russell, Executive.

Monitoring and 638 Contract Close-out. Contract Monitoring and Close-out After Award ▫ Meet with Tribe to discuss the Agreement  Include Monitoring Plan.

Health Reform 101 National Tribal Health Reform Implementation Summit April 19, 2011 Jennifer Cooper Legislative Director, National Indian Health Board.

Health Reform Implementation -- Federal Regulations -- Presentation to the NIHB Annual Consumer Conference September 28, 2011 Doneg McDonough Technical.

Ready for Reform! Medicaid Payments for Four Provider Types: Medical, Dental, Mental Health and Chemical Dependency November 18, 2015, Managed Care Organizations.

Ready for Reform! Medicaid Expansion: Evidence of Success from Washington State Paid Claims Database October 26, 2015, Oregon Tribal Health Directors Meeting.

Medical Manager Unit 2 ICBS 170. MEDICAL MANAGER Each time a new patient visits the medical office the following information is added or updated and stored.

Self Determination Statewide Self Advocacy Network Adapted from information by Regional Offices 10 & 4. 11/20/15.

Lesa Evers Tribal Relations Manager Department of Public Health and Human Services State of Montana for 2015 Cover Montana Outreach & Enrollment Summit.

Community Health Action Information Network Surprise Medical Bills Advocacy in Florida February 4, 2016 Laura Brennaman, PhD RN Policy & Research Director,

 “Excellence in Rural Health Care”.  Many transitions of Programs, Services, Functions and Activities to a Tribe under Self- Governance include existing.

Disclaimer This presentation is intended only for use by Tulane University faculty, staff, and students. No copy or use of this presentation should occur.

Indian Health Service Contract Support Costs Update 1.

Alaska Tribal Health System Tribally-Sponsored Health Insurance Program Alaska Native Tribal Health Consortium April 2016.

Leveraging the Affordable Care Act to Provide Greater Health Care Access Carolyn Crowder, Self-Governance Consultant Indian Self-Determination and Education.

Policy & Legislative Update

Health Insurance Key Definitions & Frequently Asked Questions

Important points to note – Claim Submission

Pulling back the Curtain: Understanding the medical billing process

Utilizing IPA/MOA in a Self-Governance Transition

Indian Health Care Improvement Fund Workgroup

Office of Self Governance Update – July 2018

Tribal Shares Fundamentals

Office of Tribal Self-Governance Indian Health Service (IHS)

Indian Health Service(IHS)/Tribal Health Program (THP) Reimbursement Agreements May 8, 2018 Majed Ibrahim Program Manager 5/8/2018.

IHS - CSC Update Self-Governance Meeting

IHS Headquarters (HQ) Tribal Shares

1115 Demonstration Waiver Extension Summary

Health Revenue Cycle Improvement:

Third National Medicare Congress

Randy Hughes IHS Tribal Liaison Webinar October 24, 2017

Healthcare Pricing Transparency

LEVERAGING PURCHASED/REFERRED CARE (PRC) RATES

Indirect Costs Mark W. Stout, MBA Branch Chief Indirect Cost Services Division (ICSD) Interior Business Center (IBC) U.S. Department of Interior (DOI)

Preparing an IDC Proposal and Impact on Contract Support Costs

Leveraging Medicare-Like Rates

Contract Support Costs

Theresa Galvan, Co-Chair Representing the Navajo Area

Payment System Options

Indian Health Service Office of Tribal Self-Governance Update

Behavioral Health Initiative Funding Update

Indian Health Service Office of Tribal Self-Governance Update

Presentation transcript:

ORAP UPDATE Pharmacy Benefit Managers, Collections, PRC Rates and GAO Terri Schmidt Acting Director, Office of Resource Access and Partnerships October 24,2017

Pharmacy Benefit Manager (PBM) Update BACKGROUND - TSGAC requested IHS to provide assistance in resolving denials and non-payment from PBMs and Private Insurance collections DHHS reached out to CVS/Caremark CVS/Caremark verbally agreed to identify a point of Contact for Tribes/Tribal Organizations operating under and ISDEAA agreement with IHS Claims submission process Dear Tribal Leader Letter/Dear Urban Leader Letter Outline process Provide CVS/Caremark contact information Depart. Reached out to one of the larger PBM’s and initiated discussions about these issues with representatives from CVS/Caremark’s HQ Several discussions were required for CVS/Caremark to gain an understanding of the statutory right to recovery under 1621e Earlier this month (October 2017) CVS/Caremark notified IHS they would like to discuss logistics to make sure that payments are being made accordingly to 1621e. They have verbally agreed to identify an internal POC for Tribes and Tos operating under an ISDEAA agreement with IHS, to discuss specific claims submission process with CVS/Caremark Indian Health Service / Office of Resource Access and Partnerships

PRC RATE PRC Rate regulation located at 42 CFR 136 Subpart I. Gives I/T/U’s the ability to cap payment rates to physicians and non-hospital providers and suppliers. Mandatory for IHS and Tribes can opt-in I/T/U’s can negotiate a higher rate of payment with providers Must meet a reasonable pricing arrangement Most Favored Customer Rate is a platform for negotiation I/T/U’s are responsible for rate calculations Payment amount is provider specific Indian Health Service / Office of Resource Access and Partnerships

PRC RATES In the absence of a contract or agreement with IHS or Tribes that have opt-in for a negotiated rate. The PRC Rate applies as follows When a Provider accepts a referral/request for services from an I/T/U When a Provider accepts a purchase order for services from an I/T/U When a Provider files a claim for payment When a Provider accepts payment In these instances the Provider cannot balance bill the patient Indian Health Service / Office of Resource Access and Partnerships

PRC SAVINGS Currently all IHS Areas and 9 Tribes have opted-in 5 of the Tribes use the FI Savings as of August 31, 2017 for IHS and Tribes that use the FI $221,751,836 Million Indian Health Service / Office of Resource Access and Partnerships

PRC/GAO Directors Workgroup on Improving PRC October 31 and November 1 GAO will meet with the Workgroup GAO recommendations PRC distribution methodology Indian Health Service / Office of Resource Access and Partnerships