1. www.dmas.virginia.gov 1 Department of Medical Assistance Services Provider Training for Patient Pay Claims Processing Changes eff. October 1, 2015 September 2015 www.dmas.virginia.gov 1 Department of Medical Assistance Services

2. www.dmas.virginia.gov 2 Department of Medical Assistance Services PRESENTATION OUTLINE Patient Pay Background Current Claims Processing of Patient Pay and Post Payment Audits Goals for Changes Changes Being Implemented Highlights Communication Plan

3. www.dmas.virginia.gov 3 Department of Medical Assistance Services Patient Pay for Members in LTC Members have an obligation to pay towards the cost of long-term care (LTC) services if their available income exceeds permitted allowances Patient pay is usually higher for members in a Nursing Facility because the personal needs allowance does not have to cover room and board. Many members receiving Home and Community-Based Services (HCBS) have little or no patient pay because the personal maintenance allowance covers room and board Not everyone has various special needs allowances and they may vary month to month

4. www.dmas.virginia.gov 4 Department of Medical Assistance Services Patient Pay for Members in LTC, cont. All members receiving long-term care services must have a patient pay determined but many have a zero patient pay especially for Home and Community- Based Services Patient pay will be adjusted for other allowable deductions including non-covered medical expenses or health insurance premiums

5. www.dmas.virginia.gov 5 Department of Medical Assistance Services Patient Pay Determination Providers notify the local Department of Social Services (LDSS) using the DMAS-225 (Medicaid LTC Communication Form) when members start or end long-term care services or there has been a change in circumstances, income or assets The LDSS determines the monthly patient pay and Sends Notice of Obligation to members Enters monthly patient pay information into the eligibility system

6. www.dmas.virginia.gov 6 Department of Medical Assistance Services Patient Pay Information Patient pay information has been available from the Medicaid Management Information System (MMIS) since 2009 Providers have multiple sources for patient pay Automated Response System (ARS) Virginia Medicaid Web Portal Medicall Health Care Eligibility Benefit Inquiry and Response Transaction (270/271) AS-O-317 for Nursing Facilities and Intermediate Care Facilities for individuals with Intellectual Disability

7. www.dmas.virginia.gov 7 Department of Medical Assistance Services Current Claims Processing The provider with the most billing is “assigned” the patient pay amount to collect If this provider doesn’t collect the full amount, technically another provider is supposed to Provider enters patient pay amount on claim Medicaid Management Information System (MMIS) reduces paid amount by the amount of the patient pay on the claim (not the patient pay in the MMIS) The contractor Public Partnerships LLC (PPL) is responsible for deducting patient pay from consumer directed claims using patient pay from the system

8. www.dmas.virginia.gov 8 Department of Medical Assistance Services Post Payment Patient Pay Audits The contractor MSLC audits Nursing Facility Patient Fund Accounts including patient pay every two years MSLC samples at least 25% of claims Error rate ranges from 1%-3% No routine patient pay audits of Home and Community-Based Services

9. www.dmas.virginia.gov 9 Department of Medical Assistance Services Goals for Changes Fully automate the claims pricing using the “official” patient pay from the Medicaid Management Information System Ensure that claims are reduced by the correct amount Implement changes across most long-term care providers Coordinate with consumer directed claims processed by PPL No change for services for members in the Intellectual Disability, Developmental Disability or Day Support waivers Eliminate Nursing Facility audits of patient pay

10. www.dmas.virginia.gov 10 Department of Medical Assistance Services Claims Processing Changes When claims are priced, the Medicaid Management Information System (MMIS) will utilize the official patient pay determined by the local Department of Social Services Patient pay will be deducted on a first in first out date of adjudication basis each month The MMIS will track patient pay “utilization” for every month Multiple providers may be responsible for patient pay The MMIS will generate a monthly “discrepancy report” to identify any retroactive patient pay changes for which manual claim adjustments should be made

11. www.dmas.virginia.gov 11 Department of Medical Assistance Services Providers/Services Included New process applies to all institutional services (Nursing Facility or Intermediate Care Facility), Hospice and PACE (Program of All-Inclusive Care for the Elderly) New process applies to claims for the following Home and Community-Based Services Agency Personal or Respite Care (exceptions) Private Duty Nursing Adult Day Health Care (exceptions) New process does not apply to services that typically have not been responsible for collecting patient pay

12. www.dmas.virginia.gov 12 Department of Medical Assistance Services Coordination with Consumer Directed Services PPL already has well-established procedures for ensuring that patient pay is deducted from consumer directed claims payments New patient pay processing logic will be bypassed when consumer directed personal care is an authorized service If consumer directed personal care is authorized, PPL will deduct patient pay from all consumer directed claims

13. www.dmas.virginia.gov 13 Department of Medical Assistance Services Services for ID/DD/DS Waiver Members No change for services for members in the Intellectual Disability, Developmental Disability or Day Support waivers The case manager or support coordinator continues to coordinate which provider collects patient pay and deducts the patient pay on the claims If consumer directed personal care is authorized, case managers have been requested to defer to PPL

14. www.dmas.virginia.gov 14 Department of Medical Assistance Services Claims Payment “Errors” If the patient pay used on the claim appears to be incorrect, verify the patient pay used in the claim calculation with the patient pay available on the system. If the patient pay deducted on the claim exceeds the patient pay available on the system, call the HELPLINE unless the patient pay was updated after the date on the Remittance Advice. If the patient pay was updated after the date on the Remittance Advice, DMAS will adjust the claim manually within 30-60 days after receiving a discrepancy report which will be automatically generated by the system at the end of each month. If the claim has not been adjusted in that timeframe, call the HELPLINE.

15. www.dmas.virginia.gov 15 Department of Medical Assistance Services If Patient Pay has not been Updated Provider must submit a new DMAS 225 to the local Department of Social Services (LDSS) with updates If provider has submitted DMAS 225 Provider should contact LDSS if not updated in 30 days Provider should contact LDSS supervisor if not updated in 45 days Provider should call HELPLINE if not updated in 60 days Patient pay updates will be given a high priority if the member has transitioned from an institution to Home and Community Based Services (because the patient pay amount will be reduced significantly)

16. www.dmas.virginia.gov 16 Department of Medical Assistance Services Providers - Multiple Provider Questions Providers now should expect patient pay will be deducted from claims on a first come first served adjudication basis As a result, patient pay may be deducted from more than one provider when The member transitions from NF to NF, from NF to HCBS or from HCBS to NF A member receives more than one HCBS service subject to the new patient pay claims process Providers should not collect more patient pay from a member than has been withheld on his or her claim even if it is less than the member’s patient pay obligation Providers must return an excess patient pay collected

17. www.dmas.virginia.gov 17 Department of Medical Assistance Services Provider Doesn’t Bill for Patient Pay In the past, some providers may have only billed for services after the patient pay was collected If the provider doesn’t bill for all services, the Medicaid Management Information System cannot track patient pay Providers must bill for all services even if the patient pay would exceed the paid amount for an individual claim

18. www.dmas.virginia.gov 18 Department of Medical Assistance Services “Retroactive” Patient Pay Under current policy, retroactive patient pay should only happen on a limited basis when patient pay is reduced Increases in patient pay should only be entered prospectively DMAS will adjust any claims affected by retroactive patient pay changes within 30-60 days of the end of the month of the retroactive change

19. www.dmas.virginia.gov 19 Department of Medical Assistance Services CCC Members Claims for members in Commonwealth Coordinated Care (CCC) demonstration for dual eligible members are not processed in the Medicaid Management Information System and therefore these changes do not affect members in CCC CCC Medicare Medicaid Plans (MMPs) plan to incorporate similar claims processing rules Any questions about claims for CCC members should be referred to MMPs

20. www.dmas.virginia.gov 20 Department of Medical Assistance Services Communication Plan Medicaid Memo-September 2, 2015 Patient Pay Fact Sheet posted to LTC web page-will be updated regularly in response to questions Modified DMAS-225 last year Modified Notice of Obligation that patient pay may be collected by multiple providers and eliminated any provider designation In the process of modifying service authorization letter to discuss new patient pay claims process Recorded Webex training and live Q and A sessions