Mandatory Consultant Training

Health Center Program Site Visit Guide and Sliding Fee Discount and Related

Billing and Collections Program Requirements Updates

November 20th, 2014 Bureau of Primary Health Care

Health Resources and Services Administration Department of Health and Human Services

2

Agenda • Overview of Site Visit Guide Updates • Key Themes of PIN 2014-02: Sliding Fee Discount and

Related Billing and Collections Program Requirements • Implementation of PIN 2014-02 in Updated Site Visit

Guide Questions • Next Steps and Resources • Questions and Case Discussion NOTE: Slides and session content are intended for MSCG consultants ONLY and are not to be distributed beyond this purpose.

3

Homework Completed Prior to Today’s Training Session

• PIN 2014-02: http://www.bphc.hrsa.gov/policiesregulations/policies/pin201402.html

• Excerpt of Revised Site Visit Guide • PIN 2014-02 Webinar:

http://www.bphc.hrsa.gov/policiesregulations/policies/pin201402.html

4

Health Center Program Site Visit Guide OVERVIEW OF UPDATES

5

Health Center Program Site Visit Guide Updates

Focus and Goals of Updates and Enhancements:

• Respond to critical areas for improvement and clarity identified by health centers, PCAs, BPHC staff, consultants and other stakeholders.

• Align with new policy: PIN 2014-02: Sliding Fee Discount and Related Billing and Collection Program Requirements

• Ensure that OSVs and other health center site visits continue to provide consistent and comprehensive information that benefit both BPHC and health centers.

6

Health Center Program Site Visit Guide Updates PR 2: Required and Additional Services • Questions for assessing and documenting

compliance with the Required and Additional Services program requirement modified.

• Assessments of compliance specific to the

application of sliding fee discounts to required and additional services will now be documented under the Sliding Fee Discount program requirement.

7

Health Center Program Site Visit Guide Updates PR 7: Sliding Fee Discounts and PR 13: Billing and Collections Questions for assessing and documenting compliance with these requirements updated to align with the 2014 Sliding Fee Discount and Related Billing and Collections Program Requirements policy (PIN 2014-02).

8

Health Center Program Site Visit Guide Updates PR 17: Board Authority • Question for assessing whether the board meets monthly

under the Board Authority clarified as all organizations, including those that were developing plans to meet monthly due to being waived out of this requirement previously, are now required to implement these actions.

• These organizations are to be assessed for compliance

regardless of previous waiver status for monthly meetings in accordance with the Health Center Program Governance policy (PIN 2014-01).

9

Health Center Program Site Visit Guide Updates General/Throughout the Guide: • All references to Financial Recovery Plans have

been removed as HRSA/BPHC is no longer requiring or utilizing these plans.

• Other minor updates made throughout (e.g.,

clarifying certain questions, updating PINs/PALs and links).

10

KEY POLICY THEMES

PIN 2014-02: Sliding Fee Discount and Related Billing and Collections

11

Key PIN 2014-02 Themes • Flexibility on How to Implement

Requirements - With Flexibility comes Responsibility

• Role of the Governing Board (Policies versus Procedures)

• First Establish the Fee Schedule then apply Sliding Fee Discounts

12

Key PIN 2014-02 Themes

• The Sliding Fee Discount Schedule is about reducing barriers to care o Eligibility for SFDS based on income and

family size and no other factors, including special populations or insurance status

o Nominal charges are nominal from the perspective of the patient and not intended to maximize revenue

o With Flexibility comes Responsibility!

13

Key PIN 2014-02 Themes

• In balancing maximizing revenue and ensuring that no patient is denied services based on an inability to pay, patient access is prioritized. o Cannot require patients to enroll in

insurance o Must have provisions for waiving charges o “Reasonable efforts” to secure payment

from patients o With Flexibility comes Responsibility!

14

Balancing the Sliding Fee Discount and Billing and Collections Program Requirements

15

IMPLEMENTATION IN UPDATED SITE VISIT GUIDE

PIN 2014-02: Sliding Fee Discount and Related Billing and Collections Program Requirements

16

Assessing Compliance with the Sliding Fee Discount Requirement: Updated Site Visit

Guide Questions

Are the core aspects of the sliding fee discount program (SFDP) addressed in the health center’s written board-approved policies and/or supporting operating procedures? o Definitions/eligibility based on income and family size o Methods in place to make patients aware of SFDP

Has the sliding fee discount program been evaluated, or is

there a plan to ensure it will be evaluated, at least once every 3 years from the perspective of reducing patient financial barriers to care?

17

Assessing Compliance with the Sliding Fee Discount Requirement:

Updated Site Visit Guide Questions Are all of the health center’s SFDS compliant in terms of

structure, e.g., number of discount pay classes, alignment with current Federal Poverty Guidelines (FPG)?

If the health center elects to have a nominal charge for

patients at or below 100% of FPG: o Can the health center document this is nominal from the

perspective of the patient and how they determined this? o This is a fixed fee and does not reflect the true cost of

the service(s) being provided? o Is no more than fee paid by a patient in the first SFDS

pay class above 100 percent of the FPG?

18

Assessing Compliance with the Sliding Fee Discount Requirement:

Updated Site Visit Guide Questions

Are sliding fee discounts applied to all services within a health center’s approved scope of project for which there is an established charge, regardless of the service type (required or additional) or mode of delivery (direct, by contract, or by formal referral agreement)? o Previously assessed under PR 2. Required and

Additional Services. o Specifics requirements based on service delivery mode. o Acceptable to review a sample of contracts (Form 5A,

Column II services) or referral arrangements (Form 5A, Column III).

o “Good Deal” exception/flexibility for referred services.

19

Assessing Compliance with the Sliding Fee Discount Requirement:

Updated Site Visit Guide Questions

Does the health center assess all patients for income and family size and inform them of their SFDP eligibility? o Includes insured patients o If health center is not further discounting amounts to

otherwise eligible insured patients, health center can document they are subject to limitations required by the insurer due to applicable federal and state law for Medicare and Medicaid and/or terms and conditions of private payor contracts.

20

Assessing Compliance with the Billing and Collections Requirement:

Updated Site Visit Guide Questions

Can the health center document participation in Medicaid and the Children’s Health Insurance Program (CHIP)?

Is the health center making reasonable efforts to collect

reimbursement from Medicare, Medicaid, CHIP, Marketplace qualified health plans, other public assistance programs and private third party payors? o Health center can determine which plans to participate in

based on target population. costs and benefits. Does the health center collect payments in a manner that does

not create barriers to care?

21

Assessing Compliance with the Billing and Collections Requirement:

Updated Site Visit Guide Questions

Does the health center have written board-approved policiesand supporting operating procedures for billing andcollections, that include provisions for waiving chargesconsistently?o Defined circumstances/criteria for when charges will

be waived?o Specified health center staff with authority to approve

waiving of charges?

If the health center has “refusal to pay” policies, arethese defined in policies or supporting operatingprocedures?

22

NEXT STEPS AND RESOURCES

Site Visit Guide Updates

23

Next Steps

Week of November 24th: Full Updated Site Visit Guide and Online Site Visit Report Template available.

http://www.bphc.hrsa.gov/policiesregulations/centerguide.html https://hcp.hrsa.gov/OSVRTemplate/ Week of December 1st: Recording of this training and

the post-test will be available on the MSCG website at: https://www.mscginc.com/Mscg/sendmails/Consultanttrainings.cfm

24

Next Steps – Post Test

• The post-test will be available in early December.

• Please note that, starting December 15, your participation and successful completion of the post test is mandatory prior to conducting site visits.

25

Next Steps (Continued)

OSVs on or after December 1st: Consultants begin utilizing updated Guide/Online Report Format.

As questions arise based on upcoming OSVs, please send to: logistics@mscginc.com In all cases, including when compliance is unclear please document onsite observations thoroughly; compliance assessment through OSV is critical!

26

Site Visit and Consultant Resources

• Frequently Asked Questions (FAQs) related to PIN 2014-02 will be posted on the BPHC website, and will be announced in the BPHC Primary Care Digest.http://www.bphc.hrsa.gov/policiesregulations/policies/pin201402.html

• Health Center Program Site Visit Guide:

http://www.bphc.hrsa.gov/policiesregulations/centerguide.html

• BPHC Primary Health Care Digest: http://www.bphc.hrsa.gov

27

Questions and Case Discussion

Sliding Fee Discounts

28

Questions and Case Discussion

Billing and Collections

29

Questions and Case Discussion

General Site Visit Guide

Updates/Other Areas

30

Ongoing Evaluation of Site Visit Updates and Enhancements and Further Questions

Updates and enhancements are part of an ongoing BPHC site visit quality assessment and improvement process.

Please provide feedback on any or all of the following: Updated Site Visit Guide Online Site Visit Report Format/Tool Any other aspects of the site visit process

Send questions and feedback to: logistics@mscginc.com