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

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Presentation on theme: "Update on PEND and Medicaid MCO Payment Reductions Jake O’Shea, MD, FACEP President, Virginia College of Emergency Physicians."— Presentation transcript:

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, Now applies to 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 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 – 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


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