CPSP Reimbursement Models PSC Annual Meeting November 7, 2012

Reimbursement Models Fee-For-Service Federally Qualified Health Centers (FQHC) /Rural Health Centers (RHC) Medi-Cal Managed Care

Fee-For-Service Use Z Codes (HCPCS) Get bonuses –Early entry into care - $56.63 –10 th antepartum visit - $ –Case coordination (in Z6500) - $85.34 CPSP support services can be provided alone or on same day as medical visit

Fee-For-Service Bill using regular Medi-Cal Claim Forms Submit bills to Xerox Reimbursed M/C maximum allowances

Fee-For-Service Individual Services – 23 hours total –Client Orientation, assessments, and reassessments, interventions –Reimbursed at $33.64/hr Group Classes – 27 hours total –Optional –Reimbursed at $11.24/pt/hr –Lesson plans and sign-in sheets required

Fee-For-Service Adhere to service limits Track units using Billing Summary or other tool Submit Treatment Authorization Request (TAR) to Medi-Cal Field Office for support services that exceed limits (not Ob visits)

FQHC Bill only one visit (encounter) per day –Exceptions: Patient has unrelated illness that same day Dental visit Visit defined as face to face encounter with a qualified practitioner plus incidental services

FQHC Bill using 01 for all services (not Z-codes) Reimbursement is prospective payment system No early entry or case coordination Eligible for 10 th antepartum visit

FQHC Held to same service limitations as FFS Need to use M/C Billing Summary or other tool for tracking services by unit Do not need to submit TAR to Field Office –Document medical necessity for additional units in medical record –Follow instructions for TAR in M/C Manual

FQHC Pitfalls Bill excessive units and Ob visits because “we get paid” –Since they bill 01 for everything, computer doesn’t deny any services –Can be asked for reimbursement if audited Divide services inappropriately Can only bill one patient in a group class (= one “encounter” with practitioner)

Medi-Cal Managed Care What is the Perinatal Services Coordinator’s Role in Managed Care?

Medi-Cal Managed Care Inform the providers about CPSP in managed care Collaborate with health plan liaisons: follow MOU and/or subcontracts

What to Tell Providers MCMC patients are entitled to all CPSP services as described in Title 22 regulations Don’t need to be CPSP-certified, unless required by managed care contract Benefits of being a provider

What to Tell Providers READ THE CONTRACT! CPSP is a managed care benefit All managed care enrollees eligible Reimbursement method varies by contract o Capitation or separate fee-for-service rate o Cannot bill Medi-Cal for managed care clients o May need prior authorization for high risk referrals

FQHCs & Managed Care FQHCs bill the health plan first for their contracted rate Bill M/C for the difference between their contract rate and prospective payment rate

MCMC Collaboration Meet quarterly or as directed by contract Joint trainings, as requested Be the “CPSP expert” for managed care staff Collaborative opportunities and expectations may vary depending on type of MCMC (GMC, COHS, Two-Plan)

Contact Information Joanne Roberts, PSC Los Angeles County (213)