EAPG Bi-Weekly Meeting 303 East 17 th Avenue, Denver, CO 80203. 11 th Floor Room B Conference Line: 1-877-820-7831 Passcode: 294442# Kevin Martin, Andrew Abalos, Andrew Larson Nov-03 1
GROUND RULES FOR WEBINAR • WE WILL BE RECORDING THIS WEBINAR • PLEASE MUTE YOUR LINE UNLESS SPEAKING • Please speak clearly when asking a question and give your name and hospital • We are going to try to avoid muting the phone lines to encourage conversation, so please don’t: Put us on hold • Drive in your car w/window open while listening • Sit in a noisy location • Be cautious of side conversations and language (we can hear you • and it is being recording) 2
Welcome & Introductions • Thank you for participating today! • We are counting on your participation to make these meetings successful 3
Upcoming Meetings 2017 Meetings, Conference Room 11B & 11C, 2:00pm-4:00pm 11/17/2017 12/01/2017 2018 Meetings, Conference Room 7B, 2:00pm-4:00pm 01/12/2018 01/26/2018 02/09/2018 03/02/2018 03/16/2018 03/30/2018 04/13/2018 05/04/2018 05/18/2018 06/01/2018 06/15/2018 06/29/2018 Please Note: Future 2018 Meetings will be held at 303 E. 17 th Ave Denver Conference Room 7B 4
Updates • “Lower of” pricing impacting line payments ➢ This has been/is being resolved ➢ Request for redistribution formula ▪ Outpatient Hospital Payment logic posted ➢ Non-covered revenue code logic included in November 16 th 2017 service pack ▪ Should not affect interChange pricing of EAPG claims • Line level denials ➢ EOB 2580 – Resolved as of late September ▪ DXC has not produced results of mass adjustments ▪ 10/20 Question on Denied Claim for timely filing 5
One Significant Procedure Line Number EAPG Code Proc Code EAPG Payments Billed Amounts CCR Payments CCR Payment Higher 1 471 73070 0 $888 $142.58 3 43 24545 $2848.93 $31113 $4995.5 2 471 76000 0 $1446.5 $232.25 $2,848.93 $5,370.33 EAPG Payment Higher 1 999N/A 0 $155.77 0 2 999N/A 0 $4028.4 0 3 490C1713 0 $2472 0 4 471 76001 0 $841.64 $135.13 5 43 23515 2848.93 $7777.5 $1248.76 6 999N/A 0 $2146.96 0 7 496J0690 0 $48 $7.71 8 496J1170 0 $30 $4.82 9(BLANK) J1170 0 $90 $14.45 10 496J2250 0 $90 $14.45 11 495J2405 0 $24 $3.85 12 490J2704 0 $24 0 13 496J3010 0 $90 $14.45 14(BLANK) J3010 0 $30 $4.82 15(BLANK) J3010 0 $60 $9.63 16 999N/A 0 $1502.4 0 $2,848.93 $1,458.07 Payment Similar 1 999N/A 0 $38.16 0 2 999N/A 0 $2776.11 0 3 490C1713 0 $2121.09 0 4 471 76001 0 $841.64 $135.13 5 43 27814 2848.93 $17232.5 $2766.85 6 999N/A 0 $3661.06 0 7 496J0690 0 $24 $3.85 8 496J3010 0 $30 $4.82 9 496J7120 0 $24 $3.85 10 999N/A 0 $968.07 0 $2,848.93 $2,914.50 6
Lab/Ancillaries Only Line Number EAPG Code Proc Code EAPG Weight EAPG Payment Billed Amounts CCR Payment CCR Payment Higher 1403 80048 0.18140 $34.35 $450.10 $72.27 2400 83036 0.15310 $28.99 $246.35 $39.55 3398 84443 0.07930 $15.01 $547.60 $87.92 4408 85027 0.07440 $14.09 $177.50 $28.50 $92.44 $228.24 EAPG Payment Higher 1403 80053 0.18140 $34.35 $47.05 $7.55 2400 83036 0.15310 $28.99 $45.30 $7.27 3398 84443 0.07930 $15.01 $52.90 $8.49 4408 85027 0.07440 $14.09 $42.15 $6.77 $92.44 $30.08 Payment Similar 1403 80053 0.18140 $34.35 $234.00 $37.57 2398 84443 0.07930 $15.01 $146.00 $23.44 3400 83721 0.15310 $28.99 $111.00 $17.82 4408 85027 0.07440 $14.09 $111.00 $17.82 $92.44 $96.65 7
TPL / Other Insurance and EAPGs • Discovered that TPL / Other Insurance may not always apply correctly ➢ Currently reported and applied to the line ➢ Should apply at the header to coincide with visit-based philosophy for EAPG claims ➢ Working on a change in system so that claims do not need to be rebilled ➢ Once completed, impacted claims will be reprocessed. May not occur until after claims reprocessing mid-November. 8
3M Definitions Manual • Updated licensing form on Outpatient Hospital Payment page ➢ Offer through September 2018 • Clarification from 10/20 Meeting: CPT to EAPG crosswalk is available to all who license the software from 3M via 3M website but not to licensees of just the EAPG Definitions Manual w/o the software. 9
Duplicate Edits • Implementation of header-level denials for duplicate services on EAPG claims ➢ Preservation of visit-based payment • Departure from line-level denials • Finalizing logic – will be in place for mid-November mass adjustments 10
Duplicate Edits Cont’d • Criteria: ➢ Different Claim ➢ From Date of Service on Detail less than or equal to Through Date of Service on Historical Detail ➢ Through Date of Service on Detail greater than or equal to From Date of Service on Detail ➢ Same EAPG Code ▪ Not 999, 490, 491 (Commonly setting non-payable codes) • Feedback? 11
Professional Fees Billing This is long-standing billing policy for Medicaid. The intent of the policy is to prevent double payment for services. If reimbursement for professional services is included in the hospital specific rate via the cost report, and is also billed for and reimbursed separately, then this would results in double payment. The Department will continue to evaluate this policy with hospitals through the hospital stakeholder engagement meetings to ensure the policy intent aligns with how it has been operationalized historically. 12
Professional Fees Billing “Costs associated with professional services by salaried physicians are included in the hospital's rate structure and cannot be billed separately to the Health First Colorado. Do not bill professional fees (revenue codes 0960-0989) for emergency and outpatient services as an 837 Institutional (837I) electronic transaction or on the UB-04 claim form. Professional fees for services provided in the emergency room by contract physicians must be billed by the physician as an 837 Professional (837P) electronic transaction or on the CMS 1500 claim form using the appropriate HCPCS codes. The Health First Colorado payment is made to the physician.” --- Provider IP/OP Hospital Billing Manual 13
Professional Fees Billing • Department concerns ➢ Prevent double billing ➢ Increase transparency ➢ Consistency across hospitals • Hospital concerns ➢ Being paid for services rendered ➢ Etc. 14
Professional Fees Billing • Propose all professional services be billed on 1500 • Would this cause problems for any hospitals? • If so please provide detailed explanations of how 15
340B Billing • Intent of the payment policy – the Department cannot collect rebates from manufacturer. Therefore rebates need to be reflected in payment. • Guidance has been withdrawn by HRSA in 2000, no AAC billing requirement ➢ This has also presented multiple difficulties for providers • Have received some information on costs from hospitals ➢ Illustrative of inadequacy of EAPG payments for certain 340B Drugs ➢ Comprehensive listing cannot be provided ➢ Acquisition cost cannot be provided on claim ➢ Without comprehensive information, how can 340B EAPG weights be developed? ➢ How else to pay for drugs? 16
Previous Meeting Q&A • Primary diagnosis only drives whether an account is paid by BHO or Medicaid ➢ If BHO codes are only billed on secondary diagnoses, then services are not BHO covered • EAPG Hierarchy list/manual? • Medicare secondary crossovers – how payment is calculated? 17
Requests for Additional Information • Estimated Payments versus Claim Payments • Packaged services for injection and implants • Claims with sterilization said to underpay • IV Hydration in ER as Significant Procedure 18
Questions or Concerns? 19
Contact Information Kevin Martin Fee-for-Service Manager Kevin.Martin@state.co.us Andrew Abalos Outpatient Hospital Rates Analyst Andrew.Abalos@state.co.us 20
Thank You! 21
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