NJAMHAA Member Questions re New Rates/FFS SystemMarch 2, 2016
Rate Calculations:
Wages
1. Can you provide the Bureau of Labor salaries used to set wage rates? For example what was a Psychiatrist’s annual salary in your rates? Masters positions, Bachelors positions?
Benefits
1. How many PTO (paid time off days) did you figure per year? Did it differ by position or seniority?
2. What was included under fringe benefit costs for health, dental, disability and life insurance or pension contributions for provider employees?
Staffing
1. How many extra billers did you figure we would need to do 3 x the billing we are doing today?
2. When calculating the cost per service, what was the assumed face to face time per day and did you allow for the PTO (paid time off) impact on not working every day?
3. Can you share information on how they came up with staff to client ratios and staffing patterns?
4. How much time was allowed for staff to have supervision, attend treatment team meetings, and attend training conferences?
Case Management
1. Was a factor for case management included in the substance abuse rates?
2. What factor was used for case management in mental health programs?
3. How much time was allowed for case management and collateral contacts?
Units of Service
1. In programs like Out Patient, what was assumed to be the show rate? 65%, 70%?
2. What group size was considered to determine the rates (DMHAS contract size of 12 or Medicaid limit of 8)?
3. Currently the fee for service network payment system is predicated on a one hour unit at $23/hour. The DMHAS slot contracts read one hour groups. The new rates are predicated on a 90 minute group (so the reimbursement rate is actually going down). How are agencies to avoid losing money on having groups consisting of individuals who can be billed for these different times?
Overall
1. While the new rates compare favorably to current state and Medicaid rates, they are as much as 40 to 50% lower than the 2013 statewide median costs provided by DMHAS. Contract funding helped providers to cover these actual costs; how does DMHAS expect the difference between the new rates and their own cost calculations to be made up in a FFS system?
2. What rates were used for capital costs, G&A costs, and infrastructure?
Billing:
1. Will the billing process be similar to the way we bill Medicaid today?
2. What is the expected time frame from billed date until our receipt of funds?
3. Will there be any caps or limits on the amount that we can bill FFS, such as with Partial Care?
4. PACT Services: is there an ability to bill to the State for enrolled consumers who are incarcerated or hospitalized that are still receiving PACT services and/or whose slot is being maintained for their discharge back to the community?
5. Will the state accept the same billing form that Medicaid accepts?
6. Will the state accept electronic billing?
7. Medicare does not pay for certain services. Would providers be required to bill Medicare and be denied in order to bill for state only funds?
8. Will there be enhancements to cover cost of translator for non-English speaking clients?
9. Does the new A services rate of $214.74 apply to both A GH and A apt? If not, what are the two rates?
10. Will room and board be paid for level D?
11. For room & board, will DMHAS have a contract with providers? What will be requirements for backup, for an audit trail? As a suggestion, can we use Molina as the billing agent?
12. For the State reimbursed treatment payments (for the non-Medicaid consumers), will DMHAS have a contract with providers? What will be requirements for backup, for an audit trail? As a suggestion, can we use Molina as the billing agent?
13. Who exactly is eligible for the state rate? Will they need prior authorization and by what entity?
14. Are non-Medicaid eligible consumers who are currently being served that are self-pay status (on a sliding fee scale) eligible for the state rate?
15. Will agencies bill the state rate for non-Medicaid eligible individuals through Molina?
16. What CPT codes correspond with each of the service definitions?
17. How do we distinguish between provider types in the new system (e.g. currently Individual Therapy provided by an LCSW is billed on code 90832, individual therapy provided by an APN is billed on code 90833)?
18. Will bed vacancies in crisis/respite services be reimbursed differently than other residential services as they are intended to be short-term and not permanent or longer term housing?
19. What will be the reimbursement policy for bed holds/hospitalizations?
20. Will there be an expanded MAT Intake Evaluation rate to accommodate the extra expenses of physician assessment time as well as requisite lab work and TB testing mandated by the feds and state for all MAT clientele?
21. How will providers bill for Methadone clients who are also enrolled in IOP?
22. Will there be a rate for laboratory/urine tests (drug screening)?
Third Party /Recoupment
1. Will there be specific language that recoupment only pertains to the cases billed State Only that providers apply the forthcoming sliding scale to?
2. What is the methodology that will be used to recoup excess Medicaid and Medicare?
3. How will the Division address payment to program elements that receive pass through dollars from another Division (i.e. Residential services for DDD consumers within mental health programs-DDD dollars come in through the mental health grant)
4. Regarding people who have Medicare or insurance (managed care, etc), do we get to bill the state rate for what Medicare does not cover, or for their insurance paying less or not covering something? And if yes, are we billing the full state rate, and then the state will recoup whatever we do collect, or are will billing a reduced state rate, and the financial burden of collection is on us.
For example, let’s say the state rate for a service is $100. They have insurance that pays $50 and I am supposed to bill the client their $20 co pay.What am I billing the state? Is it $50 ($100 - $50 from insurance) and then they would recoup the $20 if we collect it?
We would highly recommend that the state rate be kept “clean” and that the state recoup collections at the end of a period. Can this be confirmed?
5. Regarding self pays, depending on where they fall on the sliding fee subsidy schedule (which varies by provider), are will billing the full state rate or are we billing a % of the state rate based on their subsidy. Again, is the burden of collecting the % of their self-pay amount on us, or the state with a recoupment?
6. Will providers be able to bill the state for the difference between private insurance and the Medicaid rate?
7. When will providers have the applicable sliding scale fees (it would bemost helpful to have them as early as possible)?
Reporting
1. Will providers need to continue the CMS system for fiscal reporting?
2. Will the QCMR reporting be phased out?
Transition:
1. When can providers expect training on the new FFS system for mental health?
2. For fiscal year agencies, will the state require a final ROE on the two quarters with state funding?
3. For the 6 month period of July 1, 2016 to December 31, 2016 (when we are still under contract), providers will see an increase in Medicaid revenues. We need to clearly understand the extent to which we can utilize those funds. Meaning, can we budget increased Medicaid revenue for this period to help us offset existing deficits, or will the state once again not permit us to increase our Medicaid budgets?
4. For mental health programs moving to FFS on Jan. 1, 2017, does the two month advance have to be paid back by the end of the state’s FY (June 30, 2017), providing only a six month payback period?
5. Has a decision been made about whether providers will be submitting a six month or full year budget for FY 2017?
Transportation
1. Partial Care Transportation: is there an ability to bill the State for non-Medicaid consumers that are transported to and from treatment by the program?
2. There were no rates provided for transportation. Are they changing?
Case Management
1. With regards to those clinics that originally were considered med monitoring clinics, and had case managers paid for by the state in their contracts for up to as many as 700 consumers who are seen in case management, do we get to bill the state for the case management for those consumers, and if yes what would the rate be?
2. For the agencies that got the outpatient co-occurring expansion grant, how do we get to bill for the case management and peer advocate service that were part of the grant?
General/Misc.
1. Will the Division consider raising level of service ceiling?
2. Will the Division consider major capitol requests?
3. Regarding “co-occurring capable”, can a CADC do any of these services? Can an LCADC do them?
4. What will be the process for expanding operations? Will there be RFPs for new programs or are we free to open new programs from community referrals?
5. Is there a mechanism in place to adjust the rates in future years for cost of living?
Comments
Two agencies that have shared revenue estimates based on the new rates have indicated they will have approximately $3 million and $1.6 million less funding in aggregate across all of their programs.
Transition/Cash Flow
A. Providers need the ability to generate working capital especially with making us assume the risk. In the children’s system, at risk providers are at risk, but are able to keep any surplus.
B. The division contract structure and regulations have not allow for accumulating working capital. Therefore providers may not be able to cover their current liabilities. Currently providers use ongoing advance contract payments and accruals to cover the cash deficit. Providing an advanced payment that must be repaid by the end of the fiscal year will not be sufficient. It is not realistic to believe that providers will be able to accumulate sufficient working capital within one fiscal year. A longer term solution is needed.
C. After waiting four years for the rates and system information, SUD programs have four months to transition and mental health programs have less than a year. The IME SUD transition time frame has already been delayed. Processing and approval of CY 2016 contract renewals submitted in October are behind. Some January and February contract payments have not been processed. This all leaves serious doubts about the transition timeline and it should be reconsidered.
Same Day Services
Regarding same day billing for Medicaid/Medicare services, with current contracts, some providers are able to afford doing this as part of a client-centered effort. For example, if an Outpatient consumer sees their APN for medication management and their therapist on the same day, scheduled for the consumer’s convenience, we cannot bill for both sessions. This will not be possible when fee for service is enacted.
Reporting
A. Apparently it was stated at arates meeting that providers will need to continue doing USTF’s and QCMR’s after fee for service goes into effect post 1/1/17. These essentially become unfunded mandates.
B. There remain serious problems with the NJSAMS system. SUD clinicians are sending in tickets and rarely getting any response. The amount of time spent on NJSAMS is extraordinary and, with a FFS system could be a significant problem. Providers have to use NJSAMS even more with the new IME system (screening tools, DASIE, etc.). To get prior authorization, this system must be running correctly.
IOTSS
1. The outpatient rates are to be used for IOTSS programs as well. The amount of non-face to face, non-billable case management services including collateral contacts, case service coordination, referral and linkage to community services and resources, advocacy, etc. are much higher in an IOTSS program than in an outpatient program. Therefore the reimbursement rates, based on outpatient computations (percent of staff time spent in face to face, billable contacts), would be inadequate for the IOTSS programs.
Medication Management
A. Is it accurate to understand Medication Management as follow-up appointments to review medications and renew prescriptions? If so, the Medicaid rates are very low ($23 and change) for most routine visits, they don't come close to covering the cost of providing the service.
B. We have concerns about medication monitoring rates not being adjusted. The DMHAS indicated they reviewed the credentials of those providing this service and believe the rate was appropriate; however, the credentials are MD and/or APN…..the most expensive resource providers employ.
DMHAS also believes the new rates will encourage more providers to accept Medicaid rates but why would docs/APNs that don’t currently see Medicaid clients for med management opt to now if med monitoring rates are unchanged?
Transportation Rates
A. The current transportation rates do not cover costs. Therefore they would also not cover any G&A, capital, supplies, and infrastructure/overheads costs.
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