Financial Workgroup Meeting Minutes August 2, 2006 (pdf)

Purpose of the teleconference meeting is to review issues associated with coordination of benefits for clients billed to DMH and develop recommendations for the SRI meeting in September.

  • Overview of issues and meeting handouts (attached) was reviewed by Randy Pletcher. Issues included:
    • Definition of usual and customary charge, whether it is based on the provider's fee schedule or the Rule 132 rate schedule, and how the resulting amount is entered into ROCs
    • Principle of equity between MCD and NMCD clients in planning for DMH fee for service structures to protect access for all clients, reduce/eliminate any financial incentives for preferring one type of client over another, and encourage application for MCD, where appropriate.
    • HFS parameters-Medicaid payment is payment in full, and consistent treatment of MCD and NMCD facilitates billing to CMS as clients' eligibility change.
    • If Rule 132 rate is payment in full several issues exist from the providers' perspective, including:
  • Providers' financial incentives to seek third party payments is reduced,
  • Provider's revenue from DHS and other payers could be reduced, and
  • Timing is problematic since eventual collections may be different from amounts billed. Mechanisms to true-up actual calculations are complex.
  • Provider discussion of issues:
    • Discrimination against MCD clients not a big issue due to provider struggling to meet MCD targets. The impact of MCD/NMCD targets depends upon each provider's particular situation.
    • Number of MCD clients with TPL is very low, but much larger volume of NMCD with small self pay amounts
    • Technical issues for retroactive MCD eligibility are complex-example of need to refund client payments if client eligibility changes from NMCD to MCD.
    • If coordination of benefits is based on provider's fee schedule, the amount paid to each provider could be different.
    • Provider's rate schedule should be usual and customary charge and that amount should be defensible based on a variety of factors.
    • Proposed calculations, which will reduce MCD/NMCD billable amounts by TPL and client payments, will result in fewer resources available in the community for mental health services.
    • Rates do not cover the costs of service, which is why the incremental reimbursement from third parties/clients payments should be available to providers.
    • MCD or NMCD eligibility not specified in ROCs until after the claim is processed.
    • Providers will admit MCD clients from out of area, but not NMCD
    • Is an incentive from the 718 fund possible?
    • All agree that MCD COB must begin with the Rule 132 rate
    • The critical issue is whether the NMCD COB calculation begins with the Rule 132 rate, the provider's fee schedule or another amount.
    • Timing is important for cash flow, so if final payment is required prior to filing, cash flow will be delayed. Also, if claims can be filed based on expected amounts and the actual collection is different, how can a true-up be claimed?
    • Is there an impact on access to service? Is there an impact on the dollars available for services?

Next Meeting

To review preliminary recommendations Monday, August 8, 1:30 - 3:30 PM.

Meeting participants:

Doug Kolasinski, Randy Pletcher, Susan Parker, Tim Sheehan, Teresa Goode, Brittan Harris, Kelly Schuler, Mike Bach, Wanda Burnett, Gongmin Mou, Rich Murphy, Heather Eagleton, Candace Clevenger, Robert Lesser, Frederica Garnett, Tom Frederick, Kathy Roberts