FQHC/RHC Enhancement into FQHC/RHC Enhancement into Managed Care RatesManaged Care Rates

April 16, 2014 April 16, 2014

Today’s TopicsToday’s Topics• Brief recap of first webinar and information

available• Reconciliation overview • Reconciliation process• Reconciliation data• Upcoming webinar session• Requests for additional sessions on specific topics

(e.g., correct submission of rosters, etc..)?

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Brief Recap of Last Week’s Brief Recap of Last Week’s InformationInformation

• Implementation set for June 1, 2014• Contract language includes language for MCOs

ready to make full encounter payments beginning in June

• All MCOs are ready and have the capability and experience with this type of payment

• Webinar available at: http://www.hca.wa.gov/medicaid/provider/Pages/webinar.aspx

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Reconciliation Overview and Reconciliation Overview and ProcessProcess

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Reconciliation Process after June 1, Reconciliation Process after June 1, 20142014

• HCA performs quarterly reconciliation with analysis based on MCO encounter data; encounter data will be shared with the clinics

• Reconciliation will be a “rolling” process:• Allows for timelines to be met• Allows for any claims not captured in the current quarter to be

captured in the following quarter with no risk of duplicate claim capture• Specific data logic outlined on handout

• Each reconciliation allows for timely adjustment to enhancement rates as needed• Lowers future risk of large pay-backs in future quarters/reconciliations• Allows process to get closer to common goal of paying full encounter

rate for qualifying services and clients

• Appeals process is not changing from the current appeals process

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Reconciliation Data beginning June 1, Reconciliation Data beginning June 1, 20142014

• Logic for counting encounters has two changes from logic currently used:• Denials will not be reversed• Fee-for-service equivalent will be used only in reconciliations for clinics

with capitated agreements; otherwise actual encounter data submitted by the MCOs to HCA will be used

• Otherwise encounter logic remains unchanged• Qualifier for managed care claims in reconciliation based on

taxonomy– RHC taxonomy – 261QR1300X– FQHC taxonomy – 261QF0400X

• No change to how global visits are reported; the only change is related to when global visits are reported for any one client

• Delivery case rate enhancement revenue will be included in each clinic’s total revenue

– Delivery case rate enhancements are not otherwise changing

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HCA Contact InfoHCA Contact InfoOffice of Rates DevelopmentOffice of Rates Development

Please direct questions regarding this process to:Melissa Usitalo – Encounter Payment Manager

melissa.usitalo@hca.wa.gov

All other program-related questions should continue being sent to:

FQHCRHC@hca.wa.gov

General questions on professional rates should be sent to Unit Manager Madina Cavendish:

madina.cavendish@hca.wa.gov

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