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April 17, 2012 Debbra Curtis, CPA – New Horizons Healthcare 1.

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Presentation on theme: "April 17, 2012 Debbra Curtis, CPA – New Horizons Healthcare 1."— Presentation transcript:

1 April 17, 2012 Debbra Curtis, CPA – New Horizons Healthcare 1

2 Medicaid reimburses FQHCs (hereafter Centers) under the Alternative Payment Methodology (APM), a cost based rate. Centers are paid an all-inclusive per visit rate based on reasonable costs as reported on its annual cost report. During the year, Medicaid pays an interim rate and reconciliation to actual costs are made with the annual cost report. Reimbursement rates are limited by urban and rural upper payment limits set annually by CMS. The reimbursement rate applicable to each Center is communicated to the Center in the Medicaid Cost Settlement letter. PHBV Partners LLP (formerly Clifton Gunderson LLP) administers Virginia’s Medicaid program by, in-part, processing cost reports and Wrap Around requests. 2

3 If Medicaid HMO payments are less than a Center’s Medicaid reimbursement rate, Medicaid pays the difference. The Wrap Around is a request for reimbursement of the difference between HMO payments received and the Medicaid reimbursement rate. PHBV Partners assigns an analyst to each center. Your cost report and Wrap Around requests are submitted to PHBV Partners to the attention of your assigned analyst. That person is your contact for questions and assistance. There are no report formats for the Wrap Around provided by PHBV Partners or Medicaid. 3

4 Frequency – There is no requirement for the frequency of submission. PHBV Partners recommend quarterly. Centers may choose to submit twice per year or only once when the cost report is prepared. Quarterly submission is recommended for cash flow purposes. Locations – For multiple locations which are included on one cost report, only one Wrap Around is prepared for each submission (one Wrap Around per group NPI number). Detail report – After deciding the period of time you will submit (i.e. January 2012 through March 2012), compile a detailed report of all Medicaid HMO visits for that period of time. All HMO payments must be accounted for before you can prepare the Wrap Around. – Detail must include a unique identifying number (EHR claim number for example), date of service, gross charge and HMO payment. – The detail report is sent with the Wrap Around request so do not include patient names, social security numbers, etc. 4

5 – Indicate the time period covered by the report. – Summarize your detailed Medicaid HMO visits into the following categories: Medical (including behavioral health) Inpatient Dental Medical FAMIS (including behavioral health) Inpatient FAMIS Dental FAMIS – NOTE – FAMIS visits must be listed separately as indicated here. – For each category total the following: Number of visits Gross Charges Payments 5

6 Center Name Medicaid Wrap Around Summary Medicaid HMO Patient Visits, Charges and Payments January 2012 through March 2012 Number of Visits Gross Charges HMO Payments Medical400 54,000 25,000 Inpatient Dental10020,000 7,900 Medical FAMIS9013,500 6,000 Inpatient FAMIS Dental FAMIS Wrap Around payment calculation: In this example, there were 490 HMO medical visits with payments of $31,000 during the three month period January 2012 through March 2012. If the Center’s Medicaid reimbursement rate is $120, the Wrap Around payment on the medical visits would be $27,800 calculated as: 490 visits x $120 = $58,800 Less HMO payments ($31,000) Wrap Around payment $27,800 Dental Wrap Around payment would be calculated the same using the Dental reimbursement rate. 6

7 Make sure your detail report totals agree to your summary totals. Retain your detail in the event you are audited and must pull individual patient records. Send your Wrap Around summary and detail reports along with a letter requesting the wrap around to: PHBV Partners LLP [Your assigned analyst’s name] 4461 Cox Road, Suite 210 Glen Allen, VA 23060 7

8 April 17, 2012 PHBV Partners LLP Ms. Your Analyst 4461 Cox Road, Ste. 210 Glen Allen, VA 23060 Re: Center name Medicaid Provider # xxxxxxxxxx Dear Ms. Analyst: Enclosed please find the Medicaid HMO Wrap Around Report for [Center name] for the period January 1, 2012 through March 31, 2012. If you have any questions regarding this report, please contact me at xxx-xxx-xxxx. Sincerely, Your Name Your title 8

9 Medicaid HMO information is included on Exhibit A. Wrap Around payments are also included. – Use your Wrap Around summaries submitted during the year for ease of entering this information. – Visit, gross charge and HMO payment information is entered by the six categories on the applicable line g-l on Exhibit A. – Wrap around information is entered at the bottom of Exhibit A (cash advances). The total carries to the applicable line g-l, column 5. 9

10 VISITS (ENCOUNTERS) TOTAL CHARGES PAID BY PRIMARY CARRIER & PATIENT PAY AMOUNT RECEIVED FROM INTERMEDIARY/HMO CASH ADVANCES TOTAL PAYMENTS 123456 1 Paid by Intermediary/HMO during the fiscal period on remittances at applicable tentative rate. g HMO Clinic 4,200 567,000 263,000 241,000 504,000 h HMO Inpatient Hospital i HMO Dental j HMO FAMIS Clinic 1,500 203,000 94,000 86,000 180,000 K HMO FAMIS Inpatient Hospital l HMO FAMIS Dental CASH ADVANCES: DATE CLINIC HMO CLINIC HMO IN-PT HOSP HMO DENTAL 11/19/2010 52,000 1/24/2011 57,000 5/2/2011 56,000 7/25/2011 76,000 241,000 FAMIS CLINIC HMO FAMIS CLINIC HMO FAMIS IN-PT HOSP HMO FAMIS DENTAL 11/19/2010 17,000 1/24/2011 18,000 5/2/2011 22,000 7/25/2011 29,000 86,000 *this cost report excerpt does not include all lines on Exhibit A. Only certain lines are included here for purpose of this example. 10

11 Questions? 11

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