IHS/CHS Fiscal Intermediary What Can It Do For Tribes? Blue Cross and Blue Shield of New Mexico 2007

IHS/CHS FI Functions Administration Operations Team Program Management 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

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

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

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)

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

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

FI Supported Non-Medicare Based Reimbursement 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

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

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

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

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

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

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)

Contract Standards The IHS/CHS FI contract standards include: 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

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

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

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.

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