Clinics and Health Centers Services
Myers and Stauffer has assisted state Medicaid agencies with reimbursement changes for federally qualified health centers (FQHC), rural health clinics (RHC), and community mental health centers (CMHC), and other types of clinic providers since the Medicare, Medicaid, and State Children’s Health Insurance Program (SCHIP) Benefits Improvement and Protection Act of 2000 (BIPA) was enacted. BIPA replaced cost-based reimbursement systems for FQHCs and RHCs with a prospective payment system (PPS). The PPS established a federal requirement that FQHCs be reimbursed at a minimum rate for services provided to Medicaid patients. Community mental health centers support and treat individuals with behavioral health needs in a community setting, rather than an inpatient setting. CMHCs offer a wide variety of services to patients based on their specific needs and are required to maintain an active person-centered treatment plan for each individual served.
Myers and Stauffer assists state Medicaid agencies with cost report design and implementation, development and modeling of reimbursement methodologies, provider training, stakeholder engagement, data collection, policy recommendations, and program evaluation and sustainability. In managed care states, our role has expanded to assist state agencies with “wrap-around” or supplemental payments in order to ensure providers continue to be reimbursed at levels mandated by BIPA.
We provide the following services:
Audit and Attest
Bob Hicks, CPA
Our professionals have experience validating costs reported by clinics such as FQHCs and RHCs. These audits were initially used to establish reimbursement rates and calculate settlement amounts. Through reimbursement changes mandated by BIPA, we assist states in establishing PPS reimbursement rates for FQHCs, as well as designing and implementing procedures for rate changes related to changes in scope. Our services include:
- Validating rate change requests for change in scope.
- Calculating wrap-around payments related to reimbursement through managed care plans.
- Cost report collection.
- Web-based data exchanges for cost reports, supporting documentation, and related information.
- Cost report database management, analytics, and reporting systems.
- Audit and attest work programs and standardized work papers.
- Attest protocols compliance with state and federal definitions.
- Risk assessments to target audit work.
- Training programs for clients, clinics, and other stakeholders.
- Claims management and audit systems.
Rate Setting and Reimbursement
|Tim Guerrant, CPA
Myers and Stauffer assists state Medicaid program clients with the design, collection, and review of cost reports to establish reimbursement rates for FQHCs, RHCs, CMHCs, and other types of clinic providers. For FQHCs and RHCs, our services include establishing new PPS rates; adjusting existing PPS rates for the required Medicare Economic Index (MEI) inflationary adjustment or for changes in the scope of services; determining Medicaid cost reimbursement and settlements; performing wrap-around payments for managed care; and defending reimbursement rates and cost reimbursement findings from health care providers’ administrative and judicial challenges. Services include, but are not limited to:
- Cost report design, collection, database management and analytics.
- Cost settlement calculations and notice of program reimbursement.
- PPS rate development.
- Change in scope of services rate adjustments.
- Managed care organization (MCO) wrap-around payment reconciliations.
- Policy analysis such as new provider rates, services included in rates, single or multiple PPS rates, etc.
- Develop and update fee schedule rates.
- State plan amendment and administrative code drafting and consulting.
Medicaid Financing and Reporting
|Tim Guerrant, CPA
Since 2014, federal requirements stipulate that Medicaid programs must submit upper payment limit (UPL) demonstrations on an annual basis for clinic services. Clinic UPL demonstrations typically include ambulatory surgery centers (ASC) and end-stage renal disease (ESRD) clinics and may also include CMHCs and clinics reimbursed on a fee schedule basis. Methodologies for demonstrating compliance include comparing Medicaid reimbursement to Medicare ASC rates, ESRD rates, or physician fee schedule rates. Myers and Stauffer is available to assist our state Medicaid clients with these compliance requirements. Our services include:
- UPL compliance options analysis.
- Federal UPL compliance demonstration.
- Fiscal impact estimate calculations.
Delivery System and Payment Transformation
|Jerry Dubberly, PharmD
Improving quality, outcomes, and patient experiences requires a fresh new perspective – a new way of thinking in an environment that has been traditionally under-funded and heavily utilized. We proudly support our clients through the most significant period of change since the inception of the Medicare and Medicaid programs. Our services include:
- Integration of behavioral health and physical health.
- Value-based purchasing models.
- Introduction of quality measures.
- Certified community behavioral health clinics (CCBHC) (next generation/replication).
|Ryan Farrell, CFE
Through our benefit/program integrity services, Myers and Stauffer assists our government health care clients as they review clinic claims to ensure provider payments are made in accordance with applicable state regulations and policies. Our services focus not only on the adequacy of documentation and the accurate coding of services, but on schemes typical of clinics, including but not limited to: misrepresenting servicing provider, billing for physician-administered service when actually self-administered, and services not rendered. Our program integrity services include:
- Claims analysis.
- Post-pay claims audits – clinical and financial.
- Pre-pay claims audits – clinical and financial.
- Medicaid recovery audit contractor (RAC) services.
- Software modules for surveillance and utilization review subsystem (SURS), fraud and abuse detection services (FADS), and case tracking.
- Provider compliance.
- Payment system processing accuracy.
- Fraud, waste, and abuse detection (FWAD) litigation support.
Managed Care Oversight and Compliance
|Mike Johnson, CPA, CFE
The extensive services offered by our highly skilled managed care team are generally focused on the oversight of health plans but can impact all provider types, including clinics. These services include:
- Encounter data reconciliation and validation.
- Financial audits, performance audits, and program effectiveness audits.
- Network adequacy assessments and member access compliance.
- Readiness reviews.
- Claims payment and denial assessments, accuracy, and timeliness.
- Medical record review.
- Grievance and appeals analysis.
- Contract compliance.
- Other provider-specific issue review and resolution activities.