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Update on PEND and Medicaid MCO Payment Reductions

Update on PEND and Medicaid MCO Payment Reductions. Jake O’Shea, MD, FACEP President, Virginia College of Emergency Physicians. 2 Medicaid Delivery Systems in Va. DMAS (“fee-for-service”) Managed care organizations (MCOs). DMAS Fee-for-service. Completely state run

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Update on PEND and Medicaid MCO Payment Reductions

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  1. Update on PEND and Medicaid MCO Payment Reductions Jake O’Shea, MD, FACEP President, Virginia College of Emergency Physicians

  2. 2 Medicaid Delivery Systems in Va • DMAS (“fee-for-service”) • Managed care organizations (MCOs)

  3. DMAS Fee-for-service • Completely state run • 2012: 34% of beneficiaries / 41% of spending • $4696 per beneficiary

  4. Managed Care Organizations (MCOs) • DMAS contracts with managed care companies, who administer the policies • Medallion II contract • Examples: Anthem Healthkeepers, Virginia premier, Optima Family Care • 2012: 66% of beneficiaries / 59% of spending • $3441 per beneficiary (vs. $4696 for DMAS!)

  5. How ED Physicians get paid less • DMAS: PEND • Aka ‘Pend, review, and reduce’ level 3 claims • MCO: Reduction to ER Triage Fees

  6. DMAS: PEND • Long standing policy of DMAS to pend charges, request review of the entire chart ($$$). • If deemed non-emergent , reduced to $22.06 • Used to apply to 99281, 99282, 99283, 99284, 99285 • Now applies to 99283 only • VACEP played major role in eliminations • Not subject to VA prudent layperson standard

  7. MCOs: Reduce to ER Triage Fees • Sporadic (only 99283) until 2012, when it became more common • VA Premier and Anthem Healthkeepers • Now, 99283, 99284, and 99285 may be subject to “Prudent Layperson” review, often by a medical director • Claims are deemed “Non-emergency” and reduced to triage fee of $22.06

  8. DMAS Pend Program: History to date: • Pre-2011: Efforts with Pat Finnerty • Program narrowed from all claims to just 99283 • Opined that complete elimination required budgetary action • 2011: Budget amendment • Not adopted because of priority of “safety net” • 2012: Coalition building and budget amendment • MSV voted: Pend elimination as legislative priority • Budget amendment not adopted (transportation)

  9. Current State: Coalition • MSV support elimination of DMAS PEND • Secretary Hazel supports eliminating both DMAS PEND AND MCO “Triage fee” reductions • Theoretically DMAS can eliminate MCO reductions by changing Medallion II Contract • DMAS reluctant to do so while the fee-for-service PEND program remains on the books

  10. What’s next? • DMAS PEND program • Ask Secretary Hazel to advocate for inclusion of PEND elimination in Governor’s budget. • MCO ER Triage fee reduction: • Asked Secretary Hazel to direct MCOs to stop reducing payments to ED Providers • While working with the Administration on DMAS PEND elimination, advocate that DMAS remove ER Triage Fee language from Medallion II contract

  11. How can you help? • Participate in VACEP letter writing campaign to the Governor asking him to eliminate PEND in the budget and remove ‘ER triage fee’ language from MCO contracts. • Donate to EMPAC!

  12. Questions? Contact Jake O’Shea, MD, FACEP Email: president@vacep.net

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