1. IHS/CHS Fiscal Intermediary What Can It Do For Tribes?
Blue Cross and Blue Shield of New Mexico
2007

2. IHS/CHS FI Functions Administration Operations Team Program Management
Contract Compliance
Program Oversight
Operations Team
Program Management
Patient and Purchase Order Entry
Claims Processing
Quality Assurance
Alternate Resource Investigation
Pend Resolution
Duplicate Detection
Adjustments
Customer Service
System Coordination
Electronic Data Transfer
Provider Payment
Medical Record Review
Analysis and Reporting
DRG Validation 1

3. FI Claims Processing Claims received on paper and electronically
Purchase Delivery Order (PDO) matched with claim
Claims run through series of edits in the FI system; set to pay once edits are resolved
Duplicate claim detection

4. Coordination of Benefits
Coordination of benefits occurs on approximately 50% of all claims; IHS is payer of last resort
Critical to have updated alternate resource information on file
The FI receives COB information via:
Purchase Order
Claim
Explanation of Benefits (EOB)
Electronic Submission from IHS

5. FI Support for Medicare-like Rates
The FI system will automatically price claims at MLR, if applicable:
Diagnosis Related Groups (DRG)
Inpatient Rehab Case Mix Groups (CMGs)
Inpatient Psychiatric Facility PPS
Skilled Nursing Resource Utilization Group (RUGS)
Outpatient Payment System using Ambulatory Patient Classification (OPS-APC)
Critical Access
Children’s Hospitals (programming in process)
Cancer Centers (programming in process)
Rural Hospital Demonstration Project (programming in process)

6. FI Support for Medicare-like Rates
MLR Regulation requires the FI to use the “interim rate” from the provider specific file as the pass through reimbursement for DRG claims.
Unlike Medicare, the IHS/CHS program will not pay retrospective payments after the cost reports are settled.
Regulation allows “better than” MLR to be negotiated with providers
FI is currently programming 2 basic methods to support contracts if negotiated with providers:
Lesser of billed or Medicare
Percent of Medicare (less than 100%)
Percentage of billed not always better and is not supported as a “better than” MLR
Timely filing limits allow 2 years for providers to submit claims

7. Additional Medicare Based Reimbursement Methodologies
The FI supports additional Medicare based pricing for individual provider contracts:
Home Health Resource Groups (HHRGs)
Hospice PPS
Medicare Outpatient Cost to Charge Ratio
Fee Per Encounter
Lesser of Billed or Medicare Fee Schedule
Percentage of Medicare Fee Schedule
Medicare ESRD rates

8. FI Supported Non-Medicare Based Reimbursement Methodologies
The FI supports additional Non-Medicare based pricing for individual provider contracts:
Negotiated Per Diem
Percentage of Billed Charge
Flat Rate
Fee Per Encounter
Contract Fee Schedule
Lesser of Billed or Contract Fee Schedule
Billed Charges will be paid if not subject to MLR and no contract is in place

9. Provider Contracts / Pricing
FI creates and maintains provider, contract and pricing files
Contracts not required for Medicare-like Rates Regulation
Over 1100 active contracts and rate quotes
Interacts with 15,000 providers nationwide
FI provides contract support to Tribes through:
Evaluation of proposed contract and reimbursement methodologies
Support for contract strategy
Ad Hoc reports to compare pricing methods
Conference calls to discuss pricing options

10. Post Pay Quality Assurance Reviews
Appropriateness of care using Milliman guidelines, inpatient care
Length of stay comparisons to industry
Quality of care issues identified
Targeted reviews upon request
Performed by registered nurses and/or physicians

11. Online Access to Claim Information
Access to view the FI’s claims processing system
Available to Tribes through the IHS intranet
Functionality allows access to Tribe’s:
Patient Data
Purchase Order Data
Claim Information (shows whether pended or paid)
Provider/Vendor information
Fiscal Intermediary Reference Manual (FIRM)
Website address:

12. Data Collected by the FI
Patient Information
Alternate Resource Information
Purchase Order Information
Claim Information, including:
Financial Information - Billed / Allowed / IHS/CHS paid amounts
Diagnosis and surgical procedure
Billing coding – Revenue, CPT and HCPCS
Dates of Service
Provider Information

13. Reporting Capabilities
Recurring Reporting
Financial & program management data
Weekly, monthly, quarterly, semi-annual, annual
Ad Hoc Reporting
Unique reports for specific data needs, including:
Pricing comparisons for contract negotiation
Trending for utilization (i.e. payments for specific diagnosis)
Analysis of services for cost/benefit analysis
Many Reports provided via Web-based application
Access to reports through the Internet (24/7 access)
Online security is Tribe specific
Ability to review reports; search within reports; print entire reports or selections; import reports to text file, MS Excel or MS Word

14. Additional FI Services
Customer Service
Available Mon – Fri, 8:00 am – 5:00 pm MT
Claims Adjustments
Overpayment Recovery
Additional Payments / Late Charges
Payment Errors
Electronic Data Transfer
Electronic transmission of PDOs to FI
FI transmits EOBRs to Tribe
FI transmits Tribe’s statistical records to National Data Warehouse (NDW)

15. Contract Standards The IHS/CHS FI contract standards include:
97% Financial Accuracy
97% Data Entry Accuracy
95% of Clean Claims Paid within 21 days
95% Customer Service Accessibility
98% of Written Inquiries responded to within 5 days
98% of Ad-Hoc Reports provided within 14 days, or as otherwise negotiated

16. Deciding to Use the IHS/CHS FI
Contact CHS Director at IHS Headquarters to discuss the cost of using the IHS/CHS FI
Contact the FI to begin the data gathering process and systems programming
Tribal questionnaire

17. Tribe Requirements Use RPMS platform to issue PDOs
Maintain bank account and sufficient funds for payment
Reconcile Tribe’s bank account
Tribe and IHS sign Annual Funding Agreement
Tribe and FI sign Memorandum of Understanding (IHS reviews and signs)
HIPAA Business Associate Agreement is addendum to MOU
MOU agreement is under umbrella of the federal FI contract
Federal contract is annually renewable; expires 9/30/09

18. FI Timeline
Requires approximately 30 to 60 days of programming and system testing after all required documents and information are received by the FI.
Missing information, delays in bank account setup or delayed check testing may cause process delays.
Timeline may be extended if multiple Tribes contact FI simultaneously.

19. Questions? IHS/CHS FI Customer Service IHS Headquarters (800) 225-0241
IHS Headquarters
Brenda Smith, CHS Director
(301)