utah medicaid outpatient conversion 2011 may 19, 2011 presented by darin dennis
TRANSCRIPT
UTAH MEDICAID OUTPATIENT CONVERSION
2011
May 19, 2011PRESENTED BY DARIN DENNIS
Introductions
Purpose of Meeting
• To provide details regarding outpatient billing changes
• To solicit feedback and questions
Areas NOT affected
• Changes do NOT include:– LTAC– Ambulatory Surgical Centers– Physician– Ambulance– Inpatient
Go Live Date
• Utah Medicaid is currently on target to be ready by July 1, 2011.
• UHA has requested go live currently scheduled for August 1, 2011. Testing results will be monitored in weekly meetings.
Medicaid Outpatient Methodology
Current• Coverage is generally
revenue-code based• Reimbursement is percent-
of-charge or fee-schedule• Urban vs. Rural differential• Emergent use of the E.D.
results in higher reimbursement
Future • Coverage is procedure-code
based• Pay is APC or fee-schedule
based• No Urban/Rural differential• No emergency differential• Use Medicare’s Outpatient
Code Editor• Use CMS’ outpatient pricer• If not covered by Medicare,
use Medicaid fee schedule
Medicare Methodology
• Hospitals identified as Critical Access Hospital or OPPS facility
• Line item procedure code receives Status Indicator (A-Z) indicating coverage and payment
Medicaid Changes
• Important to bill all codes & charges (determines outlier payments)
• All lines require a procedure code for payment• Most (~90%) of the procedure codes that
Medicare covers (9,300 codes) for outpatient will be covered by Medicaid (8,400 codes).
Medicaid Plans Affected
• Traditional & Non-Traditional plans will have similar coverage (see procedure code list)
• Primary Care Network plan coverage will only include Revenue code 045X with an emergency diagnosis (no change).
Medicaid vs. Medicare
• Outpatient definition (Medicaid=24 hour limit)• Always include NDC on pharmaceuticals
(needed for rebates)• As a general rule for Medicaid: Experimental,
investigational, cosmetic and fertility-related procedures are not covered
• Medicaid copayments are still utilized
Medicaid – Additional changes
Recently approved to use:• Modifiers• Condition codes• Revenue Codes (90% of codes opened)• Occupational Therapy and Physical Therapy
will keep submission differences• Post-Payment audits will occur (like Medicare)
Other questions
• Prior Authorization• Payment dispute and over/under payment
resolution instructions• 835 processing: Delays or suspensions plan• Crossover claims: when to bill as regular fee-
for-service