PCS (PCP Rate Parity) Option 2 Audit Overview, Results and Next Steps December 2014

PCS (PCP Rate Parity) Option 2 Audit Overview, Results and Next StepsDecember 2014

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Background• Registered AHCCCS providers elected to

participate in the Primary Care Services Program for increased payments. This program, described in Sections 1902(a) (13), 1902 (jj), 1905 (dd) and 1932(f) of the Social Security Act, authorizes increased (also referred to as “enhanced”) payments for certain E&M and vaccine codes furnished by or under the personal supervision of certain qualifying physicians for dates of service January 1, 2013 through December 31, 2014

Reaching across Arizona to provide comprehensive quality health care for those in need

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Background cont.• In order to qualify for the increased reimbursement

for primary care services, physician were required to attest to meeting one of the following requirements o Option 1) Board certified with a specialty designation of family

medicine, general internal medicine, or pediatric medicine, or a subspecialty of family medicine, general internal medicine, or pediatric medicine recognized by the American Board of Medical Specialties (ABMS), the American Osteopathic Association (AOA), or the American Board of Physician Specialties (ABPS).

• OR o Option 2) A primary care physician or subspecialist who works in one or

more of the above specialty designations but who does not have a certification specified in 1 but has billed at least 60% of Medicaid services provided, using the E&M and vaccine administration codes list at http://www.azahcccs.gov/commercial/ProviderRegistration/pcpattestation.aspx during the calendar year 2012.


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Audit Requirement and Steps Taken• The focus of todays meeting is the initial Option 2

group; future meetings will address subsequent Option 2 groups as well as the Option 1 group

• As required by federal law, the AHCCCS Administration conducted an audit of the claims and encounters for AHCCCS services provided in calendar year 2012 for physicians attesting as Option 2

• The 60% billing threshold is calculated using the following formula:o # of billed Primary Care Eligible Services (PCES) x100%o Total # of billed services for all CPT and HCPCS codes


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Audit Results• Claims and encounters for 2012 services have

been audited for all providers who attested under Option 2 to verify the physician met the 60% threshold requirement to receive enhanced fees for qualified services paid for 2013 and 2014 dates of service

• 26 Providers (see listing as of 12/1) were identified who failed this audit (meaning their qualified services based on 2012 claims and encounters did not equal or exceed 60% and AHCCCS had no verified eligible board certification for them


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Audit Results, cont.• AHCCCS and all Contractors will be required to

identify and reprocess all enhanced payments made to the final list of identified providers

• Impacted providers have been contacted multiple times by AHCCCS; Contractors will be supplied with a copy of the correspondence previously sent as well as a log of these contacts for each provider


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Audit Packages for Each Provider that will be provided to Contractors• AHCCCS has prepared individual provider audit

packages

• Intended as evidence to support the Contractors reprocessing of enhanced payments made to each provider

• Package Contents (example reviewed in meeting):o Cover Pageo Valid Board Specialties and Subspecialties Listing per CMS o PCS Processes and Audit Overviewo Procedure Code Summaryo Comprising an overall Provider Specific Exhibit (one will

be provided for each Provider identified regardless of Contractor) Reaching across Arizona to provide comprehensive

quality health care for those in need

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Next Steps and Timelines• Provide final audit results to impacted physicians

• Provide individual provider audit packages to all Contractors

• AHCCCS and Contractor must identify and reprocess all claims/encounters which received enhanced paymentso Contractor will provide notification of

reprocessing/recoupment to providers with a detailed summary including appeal rights

o Reprocessing and encounter claim submission must be completed by Contractor no later than 90 days from AHCCCS notification to Contractor

• After all reprocessing has been completed (including replacement and adjustment of impacted encounters) the Contractor must provide notification/confirmation to AHCCCS for all identified providersReaching across Arizona to provide comprehensive

quality health care for those in need

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Next Steps and Timeline• Disputes

o Contractor has responsibility to review all relevant data regarding the reprocessing decision and to ensure the information supports the reprocessing decision

o Contractor shall promptly review all information provided by AHCCCS to support the requested reprocessing and immediately notify AHCCCS with any additional information that may affect the reprocessing determination

o The Contractor is responsible for supporting the determination for any adverse action taken by the Contractor against the provider

o Contractor is responsible for supporting/defending its decision throughout the administrative dispute resolution process


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Questions?


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Thank You.


Documents

PCS (PCP Rate Parity) Option 2 Audit Overview, Results and Next Steps December 2014