Colorado Title X Family Planning Program Cost Analysis/Rate Setting Part 3: Putting it all together

PUTTING IT ALL TOGETHER Introduction

Learn to use this informatio n 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 RjAxcHFxRHVrcG8/edit Part 2: Volume and value Determined the value of everything you do Multiple value by volume Apply to MFS & RBRVS 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 Analysis CPT Code Medicare Fee Schedule Clinic Charge Master % of MFS Health Plan Rate % of MFSTarget Rate% of MFS 99203$108.19$162150%$119110%$130120% 99213$72.81$109150%$80110%$88120% 99232$70.10$105150%$77110%$84120% 99214$106.83$160150%$118110%$128120%

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

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 13 th, 2015 Contact us with any questions Don’t panic FINAL REMINDER

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