IHS/PRC FISCAL INTERMEDIARY OVERVIEW
Transcript of IHS/PRC FISCAL INTERMEDIARY OVERVIEW
![Page 1: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/1.jpg)
2019 Indian Health Service
Partnership ConferenceSpokane, Washington
IHS/PRC FISCAL INTERMEDIARY OVERVIEW
Charlene Lattier, Director
IHS/PRC Fiscal Intermediary
Blue Cross Blue Shield of New Mexico
![Page 2: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/2.jpg)
AGENDA
• Claims Processing
• Claim Pricing and Payment• Medicare-Like Rates• PRC Rates• Contracts
• Tribal Programs
• Systems & Reporting• Electronic Claims• FI Information Portal
2018 IHS PARTNERSHIP CONFERENCE 2
![Page 3: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/3.jpg)
CLAIMS PROCESSING
2019 IHS PARTNERSHIP CONFERENCE 3
![Page 4: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/4.jpg)
FI CLAIMS PROCESSING
• Claims received on paper and electronically• Inpatient / Outpatient / Professional• Dental• Non-patient specific invoices
• Purchase Delivery Order (PDO) matched with claim
• Electronic PDO received from each Area• Most Areas/Tribes waived paper PDO from
providers to accommodate electronic claims• Patient / Provider verified
2019 IHS PARTNERSHIP CONFERENCE 4
![Page 5: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/5.jpg)
FI CLAIMS PROCESSING (CONT.)
• Claim Edits• Will pend for research and/or additional
required information
• Will pend if over threshold (Tribal Program)
• Claims price at PRC rates, Medicare-like rates, or in accordance with contract/ pricing agreements
• Claims set to pay once edits are resolved
2019 IHS PARTNERSHIP CONFERENCE 5
![Page 6: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/6.jpg)
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 system is updated with COB information received via:
• Hard Copy Purchase Order
• Claim
• Explanation of Benefits (EOB)
• Electronic Submission from IHS
2019 IHS PARTNERSHIP CONFERENCE 6
![Page 7: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/7.jpg)
DATA COLLECTED
Patient Information
Alternate Resource Information
Purchase Order Information
Claim Information, including:• Financial Information - Billed / Allowed / Paid• Diagnosis and surgical procedure • Billing coding – Revenue, CPT and HCPCS• Dates of Service
Provider Information
2019 IHS PARTNERSHIP CONFERENCE 7
![Page 8: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/8.jpg)
CLAIM PRICING AND PAYMENT
2019 IHS PARTNERSHIP CONFERENCE 8
![Page 9: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/9.jpg)
PRICING PROCESS FLOW
2019 IHS PARTNERSHIP CONFERENCE 9
Processed Claim
Prices at 65% of
billed charge
Is a contract
in the system for
DOS on
claim?
Yes
Claim prices at
MLR Rate
Is a
better-than-MLR
contract on file for
provider?
No
Yes
Claim prices at
contracted rate
Is there a
Medicare rate
available?
Prices at
Medicare rate
Yes
NoNo
System checks for a
provider contract for the
DOS indicated on the claim
Claim is subject
to PRC rate
regulation
Claim is subject
to MLR
regulation
![Page 10: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/10.jpg)
FI SUPPORT FOR IHS/PRC CONTRACTING
• Database of over 15,000 providers nationwide
• Store contract and pricing information
• Provide input on pricing options and proposed contract methodologies
• Phone support to explain provider payments
2019 IHS PARTNERSHIP CONFERENCE 10
![Page 11: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/11.jpg)
MEDICARE-LIKE RATES (MLR)
Inpatient and outpatient facility services, including:
• Acute Care hospitals
• Critical Access hospitals
• Long Term Care hospitals
• Subunits of inpatient hospitals
• Psychiatric hospitals
• Rehabilitation hospitals
• Skilled Nursing Facilities
2019 IHS PARTNERSHIP CONFERENCE 11
![Page 12: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/12.jpg)
MLR PRICING
• Both Federal and Tribal claims price at MLR
• Total payment from all payers may not exceed the MLR
• Provider agreements cannot pay more than MLR
• Provider agreements can pay less than MLR (rarely used)
• Per Diem rates may be negotiated for facilities not subject to MLR
2019 IHS PARTNERSHIP CONFERENCE 12
![Page 13: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/13.jpg)
PURCHASE REFERRED CARE (PRC) RATE
1. Is there a contract or rate quote agreement in place?
If yes, price per agreement
2. Is a Medicare rate available?If yes, price at the Medicare rate
3. Price at 65% of billed charge
2019 IHS PARTNERSHIP CONFERENCE 13
![Page 14: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/14.jpg)
SERVICES SUBJECT TO PRC RATES
• Physician and other professional services
• Ambulance services
• Home health services
• Hospice services
• Ambulatory Surgical Center (ASC) services
• End Stage Renal Disease (ESRD) services
2019 IHS PARTNERSHIP CONFERENCE 14
![Page 15: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/15.jpg)
PRC RATE PRICING METHOD
The FI pays the lesser of:• The FI priced amount, or
• The patient responsibility indicated on the EOB
2019 IHS PARTNERSHIP CONFERENCE 15
![Page 16: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/16.jpg)
PRICING VIA THE MEDICARE FEE SCHEDULE (MFS)
• To price a claim, you will need the following information
• Carrier/Locality Code (location of provider)
• CPT/HCPCS code(s)
• Service date
• Units billed
• Billed amount
• Provider contract in place?
2019 IHS PARTNERSHIP CONFERENCE 16
![Page 17: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/17.jpg)
PRICING VIA THE MFS (CONT.)
In order to find the fee, determine where the provider is located (carrier and locality code).
1. Provider is located in Flagstaff, AZ - the carrier/locality code for the State of Arizona is 03102-00
2. Calculate as follows:33025 Medicare rate = $804.4792960 Medicare rate = $159.22Total allowed amount=$963.69
2019 IHS PARTNERSHIP CONFERENCE 17
![Page 18: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/18.jpg)
FEDERAL AND TRIBAL APPLICATION
• All Federal claims price at PRC Rates
• Tribal Programs are automatically opted out of PRC Rates
• Update funding agreement to opt in
• Notification received from Project Officer on effective date
2019 IHS PARTNERSHIP CONFERENCE 18
![Page 19: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/19.jpg)
PRC RATE FAQ
Are contracts and provider agreements still needed under PRC rates?
• If the provider is willing to accept the Medicare rate, an agreement is not needed.
What if the provider will not accept Medicare rates?
• Unlike MLR, you can negotiate a rate that could be higher, such as the provider’s most favored customer rate.
2019 IHS PARTNERSHIP CONFERENCE 19
![Page 20: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/20.jpg)
PRC RATE FAQ (CONT.)
Are any services not covered by PRC rates?• Non-medical services (e.g., lodging, mortuary)
• Services that are not patient-specific
• These pay at 100% billed charge unless an agreement is in place specific to the service.
What about dental, vision, and hearing providers?• Services that do not have Medicare rates will price at 65%
billed without a provider agreement.
• Consider one of the following:• Percent of billed charge
• Fee schedule (must have valid codes for billing and one fee per code)
2019 IHS PARTNERSHIP CONFERENCE 20
![Page 21: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/21.jpg)
CONTRACTS
Agreements must include…• Provider’s Taxpayer Identification Number
• Effective/term dates
• Provider’s signature/date
• Contracting officer’s signature/date
• Provider’s Medicare participating status
• Payment instructions
• W-9
2019 IHS PARTNERSHIP CONFERENCE 21
![Page 22: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/22.jpg)
TRIBAL PROGRAMS
2019 IHS PARTNERSHIP CONFERENCE 22
![Page 23: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/23.jpg)
REQUIREMENTS
• Documents• Memorandum of Understanding (MOU)• Business Associates Agreement (BAA)• Tribal Survey• Bank Account
• Electronic Transmission• PDOs generated through CHS/MIS• PDOs/EOBRs electronically sent / picked up via IHS
Network
• Contracts• Tribal Program owns the relationship with the providers
2019 IHS PARTNERSHIP CONFERENCE 23
![Page 24: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/24.jpg)
SYSTEMS AND REPORTING
2019 IHS PARTNERSHIP CONFERENCE 24
![Page 25: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/25.jpg)
SYSTEM OVERVIEW
2019 IHS PARTNERSHIP CONFERENCE 25
HHS -- UFMS
Availity
Load
DHR File
Load
UFMS Obligation File
IHS NDW
HCSC Mainframe
Check/
DOR
Manual
Entry
Claims Processing
System
Reporting Portal
Electronic
POs
Electronic
Claims
EOBR
Provider
Provider
Claims
![Page 26: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/26.jpg)
ELECTRONIC CLAIMS
What does my provider need to do to submit claims electronically?
IHS specific information is required:• 1500 (Professional) Claim Form
• Health Record Number (HRN) – Box 19 ( *Reserved)
• Purchase Order (PO) Number – Box 23 ( *Prior Authorization Number)
• UB92 (1450) (Institutional) Claim Form• Health Record Number (HRN) – Form Locator 84 ( *Remarks)
• PO Number – Form Locator 63 ( *Treatment Auth codes)
• UB04 (Institutional) Claim Form• Health Record Number (HRN) – Form Locator 80 ( *Remarks)
• PO Number – Form Locator 63 ( *Treatment Auth codes)
Provider sends claim to their clearinghouse• Provider clearinghouse sends claim to Availity• Availity sends claim to IHS/PRC FI to be loaded into the claims processing
system
Claim is processed on the night received
2019 IHS PARTNERSHIP CONFERENCE 26
![Page 27: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/27.jpg)
PRE AND POST-PAY REVIEWS
• Appropriateness of care using Milliman guidelines
• Length of stay comparisons to industry
• Quality of care issues identified
• Targeted reviews upon request
• Performed by registered nurses and/or physicians
2019 IHS PARTNERSHIP CONFERENCE 27
![Page 28: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/28.jpg)
REPORTING
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
2019 IHS PARTNERSHIP CONFERENCE 28
![Page 29: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/29.jpg)
FI INFORMATION PORTAL
Access to view real-time claim information
Access to historical reports
Available to Areas / Service Units / Tribes / HQ to access their data
Website address: www.myprcfi.com
2019 IHS PARTNERSHIP CONFERENCE 29
![Page 30: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/30.jpg)
PORTAL CONTENTS
• Purchase Order Search• Claims detail and
payment information• Provider detail• Patient detail
• Provider/Contract Search
• Medicare Fee Schedule Search
• FIRM
• Reporting Site
2019 IHS PARTNERSHIP CONFERENCE 30
![Page 31: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/31.jpg)
REPORT REPOSITORY
• Daily, weekly, and Monthly reports
• Access can be customized to view all or specific reports
• View current and prior versions of reports
2019 IHS PARTNERSHIP CONFERENCE 31
![Page 32: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/32.jpg)
COMMON REPORTS
• Verify Claim Status
• Medicare Fee Schedule
• Explanation Of Benefits (EOB)
• Pend Report
2019 IHS PARTNERSHIP CONFERENCE 32
![Page 33: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/33.jpg)
VERIFY CLAIM STATUS
2019 IHS PARTNERSHIP CONFERENCE 33
![Page 34: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/34.jpg)
VERIFY CLAIM STATUS (CONT.)
2019 IHS PARTNERSHIP CONFERENCE 34
![Page 35: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/35.jpg)
VERIFY CLAIM STATUS (CONT.)
2019 IHS PARTNERSHIP CONFERENCE 35
![Page 36: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/36.jpg)
CLAIM LEVEL
2019 IHS PARTNERSHIP CONFERENCE 36
![Page 37: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/37.jpg)
LINE LEVEL
2019 IHS PARTNERSHIP CONFERENCE 37
![Page 38: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/38.jpg)
PATIENT INFORMATION
2019 IHS PARTNERSHIP CONFERENCE 38
![Page 39: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/39.jpg)
PROVIDER INFORMATION
2019 IHS PARTNERSHIP CONFERENCE 39
![Page 40: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/40.jpg)
PROVIDER INFORMATION (CONT.)
2019 IHS PARTNERSHIP CONFERENCE 40
![Page 41: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/41.jpg)
MEDICARE FEE SCHEDULE SEARCH
2019 IHS PARTNERSHIP CONFERENCE 41
![Page 42: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/42.jpg)
EXPLANATION OF BENEFITS
2019 IHS PARTNERSHIP CONFERENCE 42
![Page 43: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/43.jpg)
EXPLANATION OF BENEFITS REPORT
2019 IHS PARTNERSHIP CONFERENCE 43
![Page 44: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/44.jpg)
PEND REPORT
2019 IHS PARTNERSHIP CONFERENCE 44
![Page 45: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/45.jpg)
PEND REPORT (CONT.)
2019 IHS PARTNERSHIP CONFERENCE 45
![Page 46: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/46.jpg)
PEND MAP
2019 IHS PARTNERSHIP CONFERENCE 46
![Page 47: IHS/PRC FISCAL INTERMEDIARY OVERVIEW](https://reader031.fdocuments.in/reader031/viewer/2022012301/61e236ff1a6c812f9932c679/html5/thumbnails/47.jpg)
QUESTIONS
2019 IHS PARTNERSHIP CONFERENCE 47