1. Medicaid update September 5, 2017 Pediatric Department Meeting
Mark Learned, MD
Medical Director, Medicaid and Charitable Programs

2. Most important – I can help you
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Mark X. Learned (even though my real middle initial is G)
Staff message
Route me a chart
Shout real loud

3. Topics Approving Home Care Face to Face visit rules
Nonmember care review
Future of Charitable Programs?
Time for questions

4. Approving home care
Medicaid rules specifically state a patient does not have to be homeb0und to receive home services
Rather, they must have circumstances that either:
Make it “more effective” to receive the service at home, or
Make it “an undue hardship” to come to an outpatient location
Despite our requests, the state has given us limited guidance on specifics

5. Then how do I make this decision?
Guiding principles:
Blanket statements like “it’s always more effective to receive services at home” are not sufficient
The request from the agency must include something unique to this particular patient
We do not need to be too strict or suspicious
If the request includes a patient-specific reason why this particular child needs home services instead of outpatient, I suggest approving it as long as it is indicated

6. Questions?

7. New face to face rule Starting this summer, new rules took effect.
These rules are already familiar to FM and IM because they copy existing Medicare policy
This rule requires a face to face visit to be done in conjunction with starting a new home service, and annually for ongoing home service
This visit CAN be with a PA or NP but the doctor has to sign the forms.

8. Face to face requirement
The visit must “relate to the primary reason” for the home health service
The visit must take place no more than 90 days before or 30 days after the start of home services
When you are initiating services based on your clinic visit this is no problem
Unfortunately in adult medicine this is the exception, and I suspect that will be true for you as well

9. Example form
Note that these are Medicare-specific requirements and will not appear on your forms.

10. Common issues Issues you will have to work around:
I didn’t order these services
I don’t know why they are getting home services
I haven’t seen them for this and now my access will suffer
A potential pitfall is when you don’t feel they qualify for home services
In that case you usually won’t get to this point (this will show up on the care plan)
If it does, this often triggers a phone visit if not a face to face visit from a disappointed patient; this is not a reason to sign for unindicated services, but just something to be prepared for
Because this is a copy of a Medicare policy, it is unlikely to change.

11. Questions?

12. Nonmember services
Remember that we have a nonmember policy statement committing us to care for nonmembers on a same day basis, as access permits.
Nonmembers booked in advance should not be rescheduled, but those are booking errors and should be turned in according to your clinic’s process.
Care for nonmembers should be restricted to “episodic” care; in other words, orders placed during that visit should be limited to that encounter.
Antibiotics for acute illness, lab or imaging to answer today’s question – all ok (unless your result might generate further intervention, like appendicitis)
Refills of chronic medications or lab/imaging related to chronic/ongoing conditions should not be offered

13. Checking coverage

14. Checking coverage
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15. Checking coverage
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16. Checking coverage
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17. Variations
Non Member Medicaid is a common one. This means they have Medicaid but it is not assigned to us. This is a nonmember. Our treatments should be limited to today’s visit as we are unlikely to be reimbursed or to generate appropriate follow up.
Non Member Insured means, as it sounds, they are not kp members but are insured by someone. Again, we are unlikely to receive reimbursement, we are unlikely to be able to follow up, and interventions should be limited to today’s visit.
Non Member Uninsured, also like it sounds, means the patient has no insurance. Interventions need to be limited to today’s visit for all the usual reasons, as well as to protect the patient financially as they will be liable for the entire bill.

18. Possible scripting “It looks like you aren’t a kp member…”
If they accept that easily, continue with “therefore we will be a little bit limited in what I can do for you today.”
If they struggle with that, I usually show them on the monitor and say, “I understand, but as long as this says Non Member, I’m pretty limited in what I can do for you. Let’s talk, and when we’re done today, I want you to talk about your file with the front desk.”
Counterintuitively, the PRAs (front desk staff) are your best source of truth for coverage questions in real time. You should trust what they say even when it conflicts with Health Connect.

19. Questions?

20. The future of charitable programs

21. The future of charitable programs

22. The future of charitable programs

23. The future of charitable programs

24. The future of charitable programs

25. The future of charitable programs

26. The future of charitable programs

27. Future state – known issues
CHP+ funding ends 9/30/17
11,000 kids at KPCO, 1,000 pregnant moms
Colorado HCPF is reforming payment structures – it isn’t a raise…
Chances are good Health Plan will see less revenue for MCP
Block grants
Work requirements
Clinical restrictions

28. Take home points Contact me if you face a Medicaid or CHP+ issue
Approve home services when indicated and when the care plan references a reasonable patient-specific factor
Remember the new face to face requirements for home services – within 30 days of initiation
Limit interventions for nonmembers to “episodic,” meaning contained within today’s visit
Turn in those misbooks when you find them
Watch for more to come on funding of charitable programs

29. Last chance for questions