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IHS/CHS Fiscal Intermediary What Can It Do For Tribes?

IHS/CHS Fiscal Intermediary What Can It Do For Tribes?. Blue Cross and Blue Shield of New Mexico 2007. IHS/CHS FI Functions. Administration. Contract Compliance Program Oversight. Operations Team. Program Management. Patient and Purchase Order Entry Claims Processing Quality Assurance

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IHS/CHS Fiscal Intermediary What Can It Do For Tribes?

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  1. IHS/CHS Fiscal IntermediaryWhat Can It Do For Tribes? Blue Cross and Blue Shield of New Mexico 2007

  2. IHS/CHS FI Functions Administration Contract Compliance Program Oversight Operations Team Program Management • Patient and Purchase Order Entry • Claims Processing • Quality Assurance • Alternate Resource Investigation • Pend Resolution • Duplicate Detection • Adjustments • Customer Service • System Coordination • Electronic Data Transfer • Provider Payment • Medical Record Review • Analysis and Reporting • DRG Validation 1

  3. FI Claims Processing • Claims received on paper and electronically • Purchase Delivery Order (PDO) matched with claim • Claims run through series of edits in the FI system; set to pay once edits are resolved • Duplicate claim detection

  4. 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 receives COB information via: • Purchase Order • Claim • Explanation of Benefits (EOB) • Electronic Submission from IHS

  5. FI Support for Medicare-like Rates • The FI system will automatically price claims at MLR, if applicable: • Diagnosis Related Groups (DRG) • Inpatient Rehab Case Mix Groups (CMGs) • Inpatient Psychiatric Facility PPS • Skilled Nursing Resource Utilization Group (RUGS) • Outpatient Payment System using Ambulatory Patient Classification (OPS-APC) • Critical Access • Children’s Hospitals (programming in process) • Cancer Centers (programming in process) • Rural Hospital Demonstration Project (programming in process)

  6. FI Support for Medicare-like Rates • MLR Regulation requires the FI to use the “interim rate” from the provider specific file as the pass through reimbursement for DRG claims. • Unlike Medicare, the IHS/CHS program will not pay retrospective payments after the cost reports are settled. • Regulation allows “better than” MLR to be negotiated with providers • FI is currently programming 2 basic methods to support contracts if negotiated with providers: • Lesser of billed or Medicare • Percent of Medicare (less than 100%) • Percentage of billed not always better and is not supported as a “better than” MLR • Timely filing limits allow 2 years for providers to submit claims

  7. Additional Medicare Based Reimbursement Methodologies • The FI supports additional Medicare based pricing for individual provider contracts: • Home Health Resource Groups (HHRGs) • Hospice PPS • Medicare Outpatient Cost to Charge Ratio • Fee Per Encounter • Lesser of Billed or Medicare Fee Schedule • Percentage of Medicare Fee Schedule • Medicare ESRD rates

  8. FI Supported Non-Medicare BasedReimbursement Methodologies • The FI supports additional Non-Medicare based pricing for individual provider contracts: • Negotiated Per Diem • Percentage of Billed Charge • Flat Rate • Fee Per Encounter • Contract Fee Schedule • Lesser of Billed or Contract Fee Schedule • Billed Charges will be paid if not subject to MLR and no contract is in place

  9. Provider Contracts / Pricing • FI creates and maintains provider, contract and pricing files • Contracts not required for Medicare-like Rates Regulation • Over 1100 active contracts and rate quotes • Interacts with 15,000 providers nationwide • FI provides contract support to Tribes through: • Evaluation of proposed contract and reimbursement methodologies • Support for contract strategy • Ad Hoc reports to compare pricing methods • Conference calls to discuss pricing options

  10. Post Pay Quality Assurance Reviews • Appropriateness of care using Milliman guidelines, inpatient care • Length of stay comparisons to industry • Quality of care issues identified • Targeted reviews upon request • Performed by registered nurses and/or physicians

  11. Online Access to Claim Information • Access to view the FI’s claims processing system • Available to Tribes through the IHS intranet • Functionality allows access to Tribe’s: • Patient Data • Purchase Order Data • Claim Information (shows whether pended or paid) • Provider/Vendor information • Fiscal Intermediary Reference Manual (FIRM) • Website address: www.mychsfi.com

  12. Data Collected by the FI • Patient Information • Alternate Resource Information • Purchase Order Information • Claim Information, including: • Financial Information - Billed / Allowed / IHS/CHS paid amounts • Diagnosis and surgical procedure • Billing coding – Revenue, CPT and HCPCS • Dates of Service • Provider Information

  13. Reporting Capabilities • 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 • Many Reports provided via Web-based application • Access to reports through the Internet (24/7 access) • Online security is Tribe specific • Ability to review reports; search within reports; print entire reports or selections; import reports to text file, MS Excel or MS Word

  14. Additional FI Services • Customer Service • Available Mon – Fri, 8:00 am – 5:00 pm MT • Claims Adjustments • Overpayment Recovery • Additional Payments / Late Charges • Payment Errors • Electronic Data Transfer • Electronic transmission of PDOs to FI • FI transmits EOBRs to Tribe • FI transmits Tribe’s statistical records to National Data Warehouse (NDW)

  15. Contract Standards • 97% Financial Accuracy • 97% Data Entry Accuracy • 95% of Clean Claims Paid within 21 days • 95% Customer Service Accessibility • 98% of Written Inquiries responded to within 5 days • 98% of Ad-Hoc Reports provided within 14 days, or as otherwise negotiated The IHS/CHS FI contract standards include:

  16. Deciding to Use the IHS/CHS FI • Contact CHS Director at IHS Headquarters to discuss the cost of using the IHS/CHS FI • Contact the FI to begin the data gathering process and systems programming • Tribal questionnaire

  17. Tribe Requirements • Use RPMS platform to issue PDOs • Maintain bank account and sufficient funds for payment • Reconcile Tribe’s bank account • Tribe and IHS sign Annual Funding Agreement • Tribe and FI sign Memorandum of Understanding (IHS reviews and signs) • HIPAA Business Associate Agreement is addendum to MOU • MOU agreement is under umbrella of the federal FI contract • Federal contract is annually renewable; expires 9/30/09

  18. FI Timeline • Requires approximately 30 to 60 days of programming and system testing after all required documents and information are received by the FI. • Missing information, delays in bank account setup or delayed check testing may cause process delays. • Timeline may be extended if multiple Tribes contact FI simultaneously.

  19. Questions? IHS/CHS FI Customer Service • (800) 225-0241 • ihsfics@bcbsnm.com IHS Headquarters • Brenda Smith, CHS Director • (301) 443-2404 • bjeanott@hqe.ihs.gov

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