Colorado Title XFamily Planning Program

Cost Analysis/Rate Setting Part 2: Volume and Value

VOLUME AND VALUEIntroduction

Objectives• Determine the value of every family planning

service you provide• Multiply the value by volume• Apply to the Medicare Fee Schedule and

RBRVS

Codes vs. Volume Spreadsheet

Site of Service• Facility: service provided in a facility (hospital,

nursing home, surgery center, etc.)– Expense RVU is lower– No overhead, staff, equipment or supplies used to

provide the service• Non-facility: services performed in the office

– Higher rate due to overhead expense– Make sure to select the correct site of service on

claim (office visit: site of service 11, box#24b)

Family Planning CPT Codes

Resource Based Relative Value Scale (RBRVS)• Implemented in 1992 by Medicare• Standardized physician payment schedule based on

cost to provide services• Three components: Work (~48%), Expense (~48%),

Liability (~4%)• Payment = Relative Value x GPCI x Conversion Factor• Commercial Health Plans: fixed fee schedule roughly

based on Medicare fee schedule

Medicare Fee Schedule (MFS)• Complete listing of maximum fees used by Medicare

to pay providers/suppliers on a fee for service basis• CMS develops fee schedules annually for physicians,

ambulance services, clinical laboratory services, and durable medical equipment prosthetics, orthotics, and supplies.

http://www.cms.gov/apps/physician-fee-schedule/overview.aspx

Medicare Allowable Codes• Changes annually• Medicare family planning codes differ from

Medicaid and other payers

Code Value• Changes annually• RBRVS trending upward each year• Make sure payers are utilizing most recent

version

Volume

What does value mean?

How to use this information• Negotiating with payers

– Share your findings• Creating sliding fee scale• Looking at productivity of your providers• Adjusting staffing

Homework• Submit a summary of cost analysis process• Form provided by RTW• Due date: February 13th, 2015 (or sooner)

Questions?