Rate Setting

Our experienced rate setting team works from the premise that government health care reimbursement rates must be accurate, transparent, and predictable, but also sufficient to support the delivery of high quality, cost-effective services, and promote good health outcomes. As a public accounting firm, we have 40 years of Medicare and Medicaid knowledge about required principles that must be followed to set rates and audit payment systems. We use that knowledge to ensure our clients’ Medicaid policy and program objectives are met while making the best use of limited public funds.

Our rate setting experience includes the following provider types:

John Dresslar, CPA


Hospital Rate Setting

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Myers and Stauffer provides our clients with hospital rate setting and related consulting services, including rate and weight setting and reimbursement system development. Our hospital rate setting services include:

  • Develop inpatient/outpatient hospital rates.
  • Diagnosis-related group (DRG) weight calculations.
  • Reimbursement system design, including:
    • DRG grouper.
    • Graduate medical education (GME) policy.
    • Ambulatory payment classification (APC) vs enhanced ambulatory patient groups (EAPG).
    • Outlier methodology.
    • Options to address neonatal, psychiatric, and rehabilitation services.
  • Supplemental payments and cost settlement calculations.
  • Quality incentive program/value-based purchasing (VBP)/pay for performance program development and oversight.
  • Budget/fiscal impact modeling.

Pharmacy Rate Setting

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Myers and Stauffer has worked with state Medicaid programs to establish levels of pharmacy reimbursement for more than four decades. We have pioneered innovative pharmacy reimbursement strategies that are based on actual drug acquisition costs as well as the true costs pharmacies experience when dispensing prescriptions. Our work has led to substantial program savings for our clients and has also created a shift in how pharmacies are reimbursed across the nation. Our services include:

  • Average acquisition cost (AAC)/state maximum allowable cost pricing methodology.
  • Specialty drug and clotting factor reimbursement.
  • Cost of dispensing surveys and professional dispensing fee consulting.
  • Consulting for 340B and value-based purchasing (VBP) issues.

Nursing Facility/LTSS Rate Setting

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Designing and implementing case mix reimbursement systems for nursing facilities is one of our firm’s core areas of expertise. In fact, we have an entire division of our organization devoted to nursing facility reimbursement. Our solutions recognize industry tendencies, trends, and incentives, while simultaneously embracing policies, processes, and reimbursement designs that meet program objectives, avoid unintended consequences, and maintain a strong, vibrant provider community that can offer high quality services to a very vulnerable population. These services include:

  • Nursing facility reimbursement design (including case mix, program design, implementation and integration into managed care).
  • Resource utilization group and Patient-Driven Payment Model (PDPM) case mix rate setting.
  • Medicare PDPM evaluation and identification of best solutions for implementing and/or modifying case mix reimbursement system.
  • Minimum data set (MDS) rate-setting rosters and case mix index (CMI) reporting.
  • On-site reviews to validate MDS assessments.
  • Quality measure reporting and consulting.
  • Clinical training.
  • Veteran’s Administration and institutions for mental disease (IMD) cost report agreed upon procedures (AUP).
  • Cost settlement calculations and notice of program reimbursement.
  • Quality incentive program/VBP/pay for performance program development and oversight.

Physician Rate Setting

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Myers and Stauffer has provided reimbursement analysis and rate setting assistance for physician services (including anesthesiology) and other ancillary services billed on the Centers for Medicare & Medicaid Services (CMS) form CMS-1500. Models prepared during these engagements included the modeling of the fiscal impact of various reimbursement rate scenarios and determining the impact according to physician specialty. Our services include:

  • Fee schedule rate setting.
  • Resource-based relative value scale (RBRVS) system updates, including relative value units (RVU) and conversion factors.
  • Quality incentive program/VBP/pay for performance program development and oversight.
  • Budget/fiscal impact modeling.

Clinic Rate Setting

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Myers and Stauffer has significant experience performing rate setting, cost settlements, and consulting services, including upper payment limit (UPL) demonstrations involving various clinic providers. Our team is skilled at establishing rates using various methodologies, including cost based rates, fee schedule rates, medians, or tiered groupings. We are knowledgeable and stay up to date regarding federal requirements and assist our clients with regulation and state plan writing when rate changes or updates occur. Our clinic rate setting services include:

  • For rural health clinics (RHC) and federally qualified health centers (FQHC), our services include:
    • Prospective payment system (PPS) rate setting in accordance with Section 702 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act (BIPA).
    • Change in scope rate setting.
    • Alternative payment methodology (APM) rate setting.
    • Managed care wrap-around payments
  • Ambulatory surgical center (ASC) rate setting and UPL.
  • Birthing center rate setting.
  • Clinical lab rate setting and UPL.
  • End stage renal disease (ESRD) rate setting and UPL.
  • Budget/fiscal impact modeling.

Behavioral Health Rate Setting

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Myers and Stauffer performs rate setting, cost report reviews, and fiscal impact analysis for behavioral health providers in both an institutional and community setting. Our services include:

  • Provider-specific or service-specific rate setting.
  • Cost report development and stakeholder training.
  • Reimbursement system design.
  • Budget/fiscal impact modeling.