# Presentation: 679118

## IHS Third Party Reimbursement Overview

***IHS Third Party Reimbursement Overview***

## BACKGROUND ITEMS

- IHS Legislative Authority, Title 18 and 19, Mcare/Mcaid in 1976, PI in IHCIA
- Special Fund/JCAHO Compliance
- BO development, 1992-93, IG Report in 1994 cited need for improvements
- IHS Business Plan, 1995
- Optimize Reimbursements to raise health status of AI/AN people

## IHS Facilities Overview

|  | Hospi-tals | Hlth Center | AK villages | Hlth Station | Res Tx Ct
 |
| --- | --- | --- | --- | --- | --- |
| IHS  | 36 | 63 | NA | 44 | 5 |
| Tribal | 13 | 158 | 160 | 76 | 28 |
| 
Physicians= 921, Nurses= 2700, Dentist= 315
Pharmacist= 411, Engineers= 350, Sanitarians= 155

Total Staff= 14,720
 |  |  |  |  |  |
|  |  |  |  |  |  |

## Total Third Party Collections1990-2000

*Total Third Party Collections**1990-2000*

## 2000 OBLIGATIONS Third Party Revenue

***2000 OBLIGATIONS ******Third Party Revenue***

## ABERDEEN AREA THIRD-PARTY REIMBURSEMENTS 1996-2000

**Notes:**
ABERDEEN AREA THIRD-PARTY REIMBURSEMENT 1995-2000

THIS BAR CHART SHOWS REIMBURSEMENTS FOR THREE THIRD-PARTY PAYERS AND THEIR TOTAL FOR 1995-2000.

## ALBUQUERQUE AREA THIRD-PARTY REIMBURSEMENTS 1996-2000

**Notes:**
ALBUQUERQUE AREA THIRD-PARTY REIMBURSEMENTS 1995-2000

THIS BAR CHART SHOWS REIMBURSEMENTS FOR THREE THIRD-PARTY PAYERS AND THEIR TOTAL FOR 1995-2000.

## BEMIDJI AREA THIRD-PARTY REIMBURSEMENTS 1996-2000

**Notes:**
BEMIDJI AREA THIRD-PARTY REIMBURSEMENTS 1995-2000

THIS BAR CHART SHOWS REIMBURSEMENTS FOR THREE THIRD-PARTY AND THEIR TOTAL FOR 1995-2000.

## BILLINGS AREA THIRD-PARTY REIMBURSEMENTS 1996-2000

**Notes:**
BILLINGS AREA THIRD-PARTY REIMBURSEMENTS 1995-2000

THIS BAR CHART SHOWS REIMBURSEMENTS FOR THREE THIRD-PARTY PAYERS AND THEIR TOTAL FOR 1995-2000.

## NASHVILLE AREA THIRD-PARTY REIMBURSEMENTS 1996-2000

**Notes:**
NASHVILLE AREA THIRD-PARTY REIMBURSEMENTS 1995-2000

THIS BAR CHART SHOWS REIMBURSEMENTS FOR THREE THIRD-PARTY PAYERS AND THEIR TOTAL FOR 1995-2000.

## NAVAJO AREA THIRD-PARTY REIMBURSEMENTS 1996-2000

**Notes:**
NAVAJO AREA THIRD-PARTY REIMBURSEMENTS 1995-2000

THIS BAR CHART SHOWS REIMBURSEMENTS FOR THREE THIRD-PARTY PAYERS AND THEIR TOTAL FOR 1995-2000.

## OKLAHOMA AREA THIRD-PARTY REIMBURSEMENTS 1996-2000

**Notes:**
OKLAHOMA AREA THIRD-PARTY REIMBURSEMENTS 1995-2000

THIS BAR CHART SHOWS REIMBURSEMENTS FOR THREE THIRD-PARTY PAYERS AND THEIR TOTAL FOR 1995-2000.

## PHOENIX AREA THIRD-PARTY REIMBURSEMENTS 1996-2000

**Notes:**
PHOENIX AREA THIRD-PARTY REIMBURSEMENTS 1995-2000

THIS BAR CHART SHOWS REIMBURSEMENTS FOR THREE THIRD-PARTY PAYERS AND THEIR TOTAL FOR 1995-2000.

## TUCSON AREA THIRD-PARTY REIMBURSEMENTS 1996-2000

**Notes:**
TUCSON AREA THIRD-PARTY REIMBURSEMENTS 1995-2000

THIS BAR CHART SHOWS REIMBURSEMENTS FOR THREE THIRD-PARTY PAYERS AND THEIR TOTAL FOR 1995-2000.

## PORTLAND AREA THIRD-PARTY REIMBURSEMENTS 1996-2000

**Notes:**
PORTLAND AREA THIRD-PARTY REIMBURSEMENTS 1995-2000

THIS BAR CHART SHOW REIMBURSEMENTS FOR THREE THIRD-PARTY PAYERS AND THEIR TOTAL FOR 1995-2000.

## FY1998-2001 Rates for the Lower 48 States

**	****	****	****           ****Medicaid****	****	****Medicare****	**
-                               I/P           O/P              O/P
- CY 1998	      $1,040	    $168	       $138
- CY1999           1,065          172                 138
- CY2000           1,157	      172	         139
- CY2001           1,306*	      185	         157
- $ Increase          149            13                    18
- % Increase        13%          8%                  13%

## 3RD PARTY REVENUE IMPACTS

- National------Laws, Regulations, Policy
- State-----------Laws, Regulations, Policy
- SU Operational improvements ie., staffing, documentation, coding training
- Leadership/Management Knowledge and Awareness Levels of issues impacting third party revenue (better decisions)
- Medicare and Medicaid Negotiated Rates
- Current and Future Health Care Delivery Changes/Trends ie., Aging, Eligibility

## IHS Unique Characteristics

- IHS charged with fulfilling Federal Government’s Health Obligation to Tribes
- Treaty Rights, Legislation, Exec. Orders
- Authority as Federal Provider to collect
- Bottom line for IHS is Increasing Health Status versus profit motive
- DHHS Secretary Special legal Authority on working with IHS ie., M & M rates
- FMAP for Mcaid is 100% Federal funds
- IHCIA---landmark legislation 1976-present

## IHS  Reimbursement Types

- Medicare Part A, Hospital charges
- DRGs for inpatient
- Encounter rate for Hospital outpatient
- Medicare Part B, Professional services
- Itemize services and receive payment under the Medicare physician fee schedule, no authority for other Part B ie., ambulance, home care, DME
- Medicaid & SCHIP
- Inpatient @ per diem rate
- Outpatient @ encounter rate (incl. Physician charge)
- For inpatient itemize physician services & bill
- @ State fee schedule
- Private Insurance bill @ fee schedule
- Other (workmen's comp, auto liability,  Commissioned Officers)

## Tribal Reimbursement Types

- Tribal Options Outpatient
- Federally Qualified Health Center (FQHC)	 for Mcare and Mcare
- Memorandum of Agreement (MOA) & use IHS outpatient rates (Mcaid only)
- Physician number @ Mcare fee schedule
- Tribal Options Inpatient
- Use IHS Rates for M Caid & Mcare DRGs
- Just like private provider (tribal facility)
- For Private Insurance same as IHS
- Itemize Outpatient and Inpatient

## 3rd Party Revenue Impacts

- Federal/State Laws, policy & regulations
-  SCHIP, Mcare Part B, Mcare Diabetes,  Hospital Provider based clinics
- M & M** **managed care initiatives
- HCFA Reimbursement policy ie., APCs, Capital payments, pharmacy
- M & M rate setting
- Cost reports (CR) effect rate
- Currently 4th year 25 hosp, 12 areas for 2002 rates,  add 11 more CR sites for 2003 Rates
- Future CR required to establish rates  & any adjustments for inflationary increases.

## 3RD Party Revenue Impacts

- Management and Operational (BO, MR & Operational/Clinical Improvements)
- Patient Registration/Alternate Res
- Provider Documentation
- Coding and Data entry
- Billing electronically
- Followup on Accts Rec
- Information System Improvements
- All payers e.g., auto liab, workmen's comp, Comm Corp, other military, MCOs

## FUTURE ISSUES/IMPACTS

- Medicare APCs-- Represents a big change for all involved SU staff, postponed until 1/2004)
- Proposed Legislative Fixes
- CHS payment at Medicare like rates for IP-save $$$
- 100% FFP for Admin---eliminate enrollment barriers
- Mcare Inpt  Phys reimb – Part B victory!
- Mcare reimb for IHS Freestanding OP clinics-victory!
- Expand  Tribal direct M & M billing and collections Demonstration—victory!
- SCHIP cost sharing exemption for Indian Children—victory!
- IHCIA Title IV changes (SSA Title 18,19,21)
- BO initiatives (see workplan)

## FUTURE  continued.................

- Strengthen HCFA/IHS Joint Steering Committee/workgroups to address National policy/reimbursement issues
- Legislative, Policy and Operations, Cost Reports/Reimb, (TAG for HCFA)
- HCFA Tribal consultation/policy development (policy papers)
- Third Party Compliance Plan (CP)
- Other Regs ie., HIPAA, M & M changes (for example, diabetes coverage, pharmacy, Mcaid expansion) etc.

## Future Continued.........

- Cost Report Development and Implications for setting rates?
- Medicare per capita Demo possibility
- DHHS/HCFA Administration  Philosophy????
- IHS/Area/SU management priorities
- Assess CAH pros and cons
- Cost Accting System/interface with RPMS

## Current Activities on Compliance

- We have simplified billing method
- Ongoing training, National & Local
- Documentation, coding, Accts Rec
- Plan development 1.5 years ago
- Currently have _____ plans in place at ______ % of hospital facilities
- Initiative to train coding staff to become certified by National bodies

## History of IHS Hospital Cost Reports for HCFA Review & Rate Setting

- 			 **Lower 48     Alaska   ****	**** Total**
- FY96 for CY98		 6	        1	     7
- FY98 for CY00		11	        3            14
- FY99 for CY01            	16              4            20
**Future Plans **
- FY00 for CY02		21	        5            26
- FY01 for CY03		32              5            37
- All Hospitals (Info)	41	        6            47

## Why do Cost Reports  

- OMB and HCFA Requirements for Setting Rates
- M&M Collections **up 100%**  ($162 M in 1995 to $363 M in 2000)   +124%
- Maintain Collections & Future Rate Adj’s??
- Maximizing Collections Critical to Improving Health Status

## Summary

- Background Authorities
- Unique characteristics of IHS
- Reimbursement levels
- Reimbursement Types
- Major Impacts on Reimbursements
- Future impacts/issues/plans/regulations
- Questions?? Comments......
- Send to Elmer Brewster, IHS HQs, OPH ebrewste@hqe.ihs.gov