10/11/2018 Emergency Department Medicaid Policy and Medicaid Update Kellie Cornelius, MAP, CPEHR, CPHIT AFMC Provider Outreach Specialist Arkansas Medicaid is the only insurance carrier in Arkansas to reimburse for three different emergency department (ED) service types that may be provided to an Arkansas Medicaid beneficiary. Assessment • Non-emergent treatment • Emergent treatment • 1
10/11/2018 Assessment Assessment is an evaluation of the beneficiary’s Assessment Assessment complaint or presenting condition. During an assessment, diagnostic testing may be performed to determine the beneficiary’s condition. Treatment that requires a skilled medical person to perform may not be given to the beneficiary. An assessment does does not not require a referral from the does does not not beneficiary’s primary care provider (PCP). However, in order for the assessment to be covered, the beneficiary being assessed must be enrolled with a PCP if their Medicaid aid category requires PCP assignment. 2
10/11/2018 Non Non- -emergent emergent treatment occurs after an assessment has been Non Non - - emergent emergent performed and the beneficiary is deemed non-emergent and is given the choice and elects to receive non-emergent treatment in the ED, rather than being discharged after receiving an assessment and referred to their PCP for follow up care. The only time Medicaid will reimburse for non-emergent treatment in the ED without a PCP referral without a PCP referral without a PCP referral without a PCP referral is when non- emergent treatment is rendered on the same day the beneficiary was assigned to a PCP by the ED. PCP assignment can be made during the beneficiary’s ED visit by calling the Voice Response System (VRS) and following the automated PCP assignment steps. The PCP assignment service must be billed on the same claim form as the non-emergent treatment. The hospital will receive a $5 fee for assigning the PCP the beneficiary selected. 3
10/11/2018 For those beneficiaries who have a PCP when they present to the ED, it’s their PCP’s discretion whether to give a referral for non-emergent treatment in the ED. This includes non-emergent treatment given in the ED after normal PCP office hours. *AFMC’s policy and education outreach services representatives educate PCPs not to give referrals to the ED for non-emergent treatment, especially during office hours. Section 213.400 of the Hospital Manual Section 213.400 of the Hospital Manual Section 213.400 of the Hospital Manual Section 213.400 of the Hospital Manual 213.400 PCP Enrollment in the Hospital Outpatient Department 10 213.400 PCP Enrollment in the Hospital Outpatient Department 10- 213.400 PCP Enrollment in the Hospital Outpatient Department 10 213.400 PCP Enrollment in the Hospital Outpatient Department 10 - -13 - 13- 13 13 - - -03 03 03 03 Medicaid covers emergency services only for recipients with no PCP. A. Staff at participating hospitals may facilitate recipients’ PCP selections. 1. A Medicaid recipient must complete a form DMS-2609, Primary Care Physician Selection and Change Form, in order to enroll with a PCP. View or print form DMS-2609 at www.medicaid.state.ar.us/Download/Provider/ ProvDocs/Forms/DMS-2609.doc 2. Hospital personnel enter the PCP selection via the Voice Response System (VRS). View or print VRS contact information at www.medicaid.state.ar.us/ Download/provider/ProvDocs/Links/PCPEnrolVRS.doc 3. The enrollment is effective immediately and its effective date is the date of entry. 4. The hospital staff must forward a copy of the form DMS-2609 to the PCP entered on the VRS and give a copy to the enrollee. B. Arkansas Medicaid reimburses hospitals (PCP Enrollment Fee — see Section 272.400 for special billing instructions) for the enrollment assistance. 4
10/11/2018 For adult beneficiaries (age 21 and over), non-emergent visits count toward the 12 outpatient hospital maximum per State Fiscal Year (SFY) July 1-June 30. Beneficiaries under age 21 are not subject to the 12 outpatient hospital benefit limit. The non-emergent PCP referral rule applies to beneficiaries of all ages. The emergent visit emergent visit is based on the prudent layperson’s definition of “emergency emergent visit emergent visit medical condition:” A prudent layperson is someone with an average knowledge of health and medicine who would expect the lack of immediate treatment to cause significant deterioration of the beneficiary’s health. From the Medicaid Manual — Section 213.300 (B): The prudent layperson standard of the Balanced Budget Act of 1997 forbids Medicaid denial of a hospital’s claim for outpatient assessment based on the discharge diagnosis. The law establishes that a person who believes he or she should seek medical attention at a hospital emergency department must be permitted to do so. Medicaid may not require the individual or the hospital to obtain prior approval for the visit and may not refuse coverage of the visit based on a non-emergent discharge diagnosis. Sudden or Recent Onset of Symptoms • Presenting Chief Complaint • 5
10/11/2018 Neither a referral nor a prior authorization is required for emergent treatment in the ED. Inpatient hospital admissions resulting from treatment in the ED do do do not do not not not require a PCP referral. Direct inpatient hospital admits by the beneficiary’s PCP do do do do require a PCP referral. 6
10/11/2018 KC1 Additional Policy References Additional Policy References Additional Policy References Additional Policy References Arkansas Medicaid Hospital Manual - https://medicaid.mmis.arkansas.gov/Provider/Docs/hospital.aspx AFMC Provider relations – policy and education https://afmc.org/health-care-professionals/arkansas-medicaid- providers/policy-and-education/ What’s New for Arkansas Medicaid Providers https://medicaid.mmis.arkansas.gov/Provider/newprov.aspx 7
Slide 14 KC1 Kellie Cornelius, 9/28/2018
10/11/2018 Episodes of Care New Episodes New Episodes New Episodes New Episodes 8
10/11/2018 PASSE Provider Provider- -led Arkansas Shared Savings Entity (PASSE) led Arkansas Shared Savings Entity (PASSE) Provider Provider - - led Arkansas Shared Savings Entity (PASSE) led Arkansas Shared Savings Entity (PASSE) Phase I – began Oct. 2017 • Independent assessments • PASSE assignment • Care coordination Phase II – Jan. 2019 • Global payment from DMS • Full risk 9
10/11/2018 PASSE Contact Information PASSE Contact Information PASSE Contact Information PASSE Contact Information • Arkansas Total Care – www.arkansastoalcare.com John Ryan – jryan@centene.com • Empower Healthcare Solutions – www.getempowerhealth.com Nicole May – nicole.may@beaconhealthoptions.com • Forevercare – www.forevercare.com Mike McCabe – MMcCabe@ForeverHealthPlan.com • Summit Community Care – www.forevercare.com Jason Miller – jason.miller@SummitCommunityCare.com Questions? Questions? Questions? Questions? 10
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