Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.20-009 - SPA #2020-0008 Physicians Evaluation and Management Code Rate Increas

Current through Register Vol. 49, No. 6, June, 2024
ATTACHMENT 4.19-B
METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES
				-OTHER TYPES OF CARE
Revised: July 1, 2020
5.
Physicians' Services
Reimbursement is based on the lesser of the amount billed or
				the maximum Title XIX (Medicaid) charge allowed. Reimbursement rates (payments)
				shall be as ordered by the United States District Court for the Eastern
				District of Arkansas in the case of Arkansas Medical Society v.
				Reynolds.
For dates of service occurring July 1, 1994 through March 31,
				2004, reimbursement rates are set at 66% of the Arkansas Physician's Blue
				CrossBlue Shield (BCBS) Fee Schedule dated October 1, 1993.
For dates of service occurring April 1, 2004 and after:
A. Reimbursement rates are increased by
ten percent (
10%
)
up to a maximum or benchmark rate
			 of eighty percent (80%) of the 2003 Arkansas Blue Cross
and
Blue
			 Shield (BCBS) fee schedule. For rates that as of March 31, 2004, are equal to
			 or greater than
eighty percent (
80%
)
of the 2003
			 BCBS fee schedule rate, no increase will be given. A minimum rate or floor
			 amount of
forty-five percent (
45%
)
of the 2003 BCBS
			 fee schedule rate will be reimbursed. For those rates that after the
ten
			 percent (
10 %
)
increase is applied are still less than the
			 floor amount, an additional increase will be given to bring these rates up to
			 the floor amount.
B. Reimbursement
			 rates are capped at
one hundred percent (
100%
)
of
			 the 2003 BCBS rate. Rates that
exceed the cap
as of March 31,
			 2004, shall be reduced in order to bring the rates in line with the cap by
			 making four equal annual reductions beginning July 1, 2005.
C. Adjustments to payment rates that are
			 comprised of two components, e.g., a professional component and a technical
			 services component, shall be calculated based on a combined payment rate that
			 includes both components. After determining the increase or decrease applicable
			 to the combined rate, the payment rate adjustment for each rate component shall
			 be apportioned as follows:
(1) Increases: If
			 one component rate, either technical or professional, exceeds the cap, the
			 entire increase shall be apportioned to the other component. If neither rate
			 component exceeds the cap, the increase shall be applied in proportion to the
			 component's ratio to the combined rate (i.e., if the technical component rate
			 is
thirty percent (
30%
)
of the combined rate
,
then
thirty percent (
30%
)
of the increase
			 shall be applied to the technical component payment rate), up to the benchmark.
			 Once a component rate is increased to the benchmark, any remaining increase
			 shall be applied to the other component.
(2) Decreases: If one component rate, either
			 technical or professional, is at the floor, the entire decrease shall be
			 apportioned to the other component. If one component rate is above the cap, the
			 entire decrease shall be apportioned to that component. If both component rates
			 are above the cap, each component shall be reduced to the cap.
D. For dates of service beginning
			 September 28, 2006, the maximum reimbursement rate for fitting of spectacles
			 (procedure code 92340) is
fifty-one dollars and twenty-two cents (
$51.22
)
. The rate is based on
eighty percent (
80%
)
of the
sixty-four dollars and two cents (
$64.02
)
,
which is the
2006 Arkansas Physician's Blue
			 Cross/Blue Shield fee schedule rate.
E.
For dates of service beginning July
			 1, 2020, the maximum reimbursement rate for evaluation and management codes
			 were increased based upon a routine rate study conducted by DMS in the Fall of
			 2019.